The correct answer is A: Household pets

46. An 80 year-old client admitted with a diagnosis of possible cerebral vascular accident has had a blood pressure from 180/110 to 160/100 over the past 2 hours. The nurse has also noted increased lethargy. Which assessment finding should the nurse report immediately to the health care provider?

A)   Slurred speech

B)   Incontinence

C)   Muscle weakness

D)   Rapid pulse

The correct answer is A: Slurred speech

47. A 3 year-old child is brought to the clinic by his grandmother to be seen for “scratching his bottom and wetting the bed at night.” Based on these complaints, the nurse would initially assess for which problem?

A)   Allergies

B)   Scabies

C)   Regression

D)   Pinworms

The correct answer is D: Pinworms

48. A 72 year-old client with osteomyelitis requires a 6 week course of intravenous

antibiotics. In planning for home care,what is the most important action by the nurse?

A)   Investigating the client’s insurance coverage for home IV antibiotic therapy

B)   Determining if there are adequate hand washing facilities in the home

C)   Assessing the client’s ability to participate in self care and/or the reliability of a caregiver

D)   Selecting the appropriate venous access device

The correct answer is C: Assessing the client'’s ability to participate in self care and/or the reliability of a caregiver

49. The mother of a child with a neural tube defect asks the nurse what she can do to

decrease the chances of having another baby with a neural tube defect.

What is the best response by the nurse?

A)  “Folic acid should be taken before and after conception.”

B)  “Multivitamin   supplements          are     recommended       during pregnancy.”

                                   

C)  “A well balanced diet promotes normal fetal development.” D) “Increased dietary iron improves the health of mother and fetus.” The correct answer is A: “Folic acid should be taken before and after conception.”

50. A PN is assigned to care for a newborn with a neural tube defect. Which dressing if applied by the PN would need no further intervention by the charge nurse?

A)   Telfa dressing with antibiotic ointment

B)   Moist sterile non adherent dressing

C)   Dry sterile dressing that is occlusive

D)   Sterile occlusive pressure dressing

The correct answer is B: Moist sterile non adherent dressing 51. A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula preparation,which of the following is most important to prevent lead poisoning?

A)  Use ready-to-feed commercial infant formula

B)  Boil the tap water for 10 minutes prior to preparing the formula

C)  Let tap water run for 2 minutes before adding to concentrate D) Buy bottled water labeled “lead free” to mix the formula The correct answer is C: Let tap water run for 2 minutes before adding to concentrate

52. A client is admitted to the rehabilitation unit following a CVA and mild dysphagia.

The most appropriate intervention for this client is

A)   Position client in upright position while eating

B)   Place client on a clear liquid diet

C)   Tilt head back to facilitate swallowing reflex

D)   Offer finger foods such as crackers or pretzels

The correct answer is A: Position client in upright position while eating

53. The nurse explains an autograft to a client scheduled for excision of a skin tumor. The

nurse knows the client understands the procedure when the client says, “I will receive tissue from…

A)   a tissue bank.”

B)   a pig."

C)   my thigh."

D)   synthetic skin."

The correct answer is C: my thigh."

54. The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis is a priority?

A)   Risk for dehydration

B)   Ineffective airway clearance

C)   Altered nutrition

D)   Risk for injury

The correct answer is B: Ineffective airway clearance

55. A client has been hospitalized after an automobile accident. A full leg cast was

applied in the emergency room. The most important reason for the nurse to elevate the casted leg is to

A)   Promote the client’s comfort

B)   Reduce the drying time

C)   Decrease irritation to the skin

D)   Improve venous return

The correct answer is D: Improve venous return

56. During the initial home visit a nurse is discussing the care of a newly diagnosed client

with Alzheimer’s disease with family members. Which of these interventions would be most helpful at this time?

A)  Leave a book about relaxation techniques

B)  Write out a daily exercise routine for them to assist the client to do

C)  List actions to improve the client’s daily nutritional intake D) Suggest communication strategies

The correct answer is D: Suggest communication strategies 57. The nurse is teaching a client with non-insulin dependent diabetes mellitus about the

prescribed diet. The nurse should teach the client to

A)   Maintain previous calorie intake

B)   Keep a candy bar available at all times

C)   Reduce carbohydrates intake to 25% of total calories

D)   Keep a regular schedule of meals and snacks

The correct answer is D: Keep a regular schedule of meals and snacks

58. The mother of a 2 month-old baby calls the nurse 2 days after the first DTaP, IPV,

Hepatitis B and HIB immunizations. She reports that the baby feels very warm, cries

inconsolably for as long as 3 hours, and has had several shaking spells. In addition to

referring her to the emergency room, the nurse should document the reaction on the

baby’s record and expect which immunization to be most associated to the findings in the infant?

A)   DTaP

B)   Hepatitis B

C)   Polio

D)   H. Influenza

The correct answer is A: DTaP

59. The nurse is teaching a class on HIV prevention. Which of the following should be emphasized as increasing risk?

A)   Donating blood

B)   Using public bathrooms

C)   Unprotected sex

D)   Touching a person with AIDS

The correct answer is C: Unprotected sex

60. The charge nurse is planning assignments on a medical unit. Which client should be

assigned to the unlicensed assistive personnel (UAP)? A client with

A)   Difficulty swallowing after a mild stroke

B)   an order of enemas until clear prior to colonoscopy

C)   an order for a post-op abdominal dressing change

D)   transfer orders to a long term facility

The correct answer is B: an order of enemas until clear prior to colonoscopy

61. A 6 year-old child is seen for the first time in the clinic. Upon assessment, the nurse

finds that the child has deformities of the joints, limbs, and fingers, thinned upper lip, and

small teeth with faulty enamel. The mother states: ”My child seems to have problems in

learning to count and recognizing basic colors.” Based on this data, the nurse suspects that the child is most likely showing the effects of which problem?

A)   Congenital abnormalities

B)   Chronic toxoplasmosis

C)   Fetal alcohol syndrome

D)   Lead poisoning

The correct answer is C: Fetal alcohol syndrome

62. The nurse has performed the initial assessments of 4 clients admitted with an acute

episode of asthma. Which assessment finding would cause the nurse to call the health care provider immediately?

A)  Prolonged inspiration with each breath

B)  Expiratory wheezes that are suddenly absent in 1 lobe

C)  Expectoration of large amounts of purulent mucous

D)  Appearance of the use of abdominal muscles for breathing The correct answer is B: Expiratory wheezes that are suddenly absent in one lobe

63. The nurse is planning a meal plan that would provide the most iron for a child with anemia. Which dinner menu would be best?

A)  Fish sticks, french fries, banana, cookies, milk

B)  Ground beef patty, lima beans, wheat roll, raisins, milk

C)  Chicken nuggets, macaroni, peas, cantaloupe, milk

D)  Peanut butter and jelly sandwich, apple slices, milk The correct answer is B: Ground beef patty, lima beans, wheat roll, raisins, milk

64. A 10 year-old client is recovering from a splenectomy following a traumatic injury.

The clients laboratory results show a hemoglobin of 9 g/dL and a hematocrit of 28

percent. The best approach for the nurse to use is to

A)   Limit milk and milk products

B)   Encourage bed activities and games

C)   Plan nursing care around lengthy rest periods

D)   Promote a diet rich in iron

The correct answer is C: Plan nursing care around lengthy rest periods

65. The nurse planning care for a 12 year-old child with sickle cell disease in a vasoocclusive

crisis of the elbow should include which one of the following as a priority? A) Limit fluids

B)   Client controlled analgesia

C)   Cold compresses to elbow

D)   Passive range of motion exercise

The correct answer is B: Client controlled analgesia 66. As the nurse provides discharge teaching to the

parents of a 15 month-old child with

Kawasaki disease. The child has received immunoglobulin therapy. Which instruction would be appropriate?

A)  High doses of aspirin will be continued for some time

B)  Complete recovery is expected within several days

C)  Active range of motion exercises should be done frequently

D)  The measles, mumps and rubella vaccine should be delayed The correct answer is D: The measles, mumps and rubella vaccine should be delayed

67. The nurse is giving instructions to the parents of a child with cystic fibrosis. The

nurse would emphasize that pancreatic enzymes should be taken

A)   Once each day

B)   3 times daily after meals

C)   With each meal or snack

D)   Each time carbohydrates are eaten

The correct answer is C: With each meal or snack 68. The nurse is assessing an 8 month-old infant with a malfunctioning ventriculoperitoneal shunt. Which one of the following manifestations would the infant be most likely to exhibit?

A)   Lethargy

B)   Irritability

C)   Negative Moro

D)   Depressed fontanel

The correct answer is B: Irritability

69. The nurse is performing a physical assessment on a toddler. Which of the following should be the first action? A) Perform traumatic procedures

B)   Use minimal physical contact

C)   Proceed from head to toe

D)   Explain the exam in detail

The correct answer is B: Use minimal physical contact 70. A client has been tentatively diagnosed with Graves' disease (hyperthyroidism).

Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse?

A)  A report of 10 pounds weight loss in the last month

B)  A comment by the client “I just can’t sit still.”

C)  The appearance of eyeballs that appear to “pop” out of the client’s eye sockets

D)  A report of the sudden onset of irritability in the past 2 weeks The correct answer is C: The appearance of eyeballs that appear to “pop” out of the client'’s eye sockets

71. Which serum blood findings with diabetic ketoacidosis alerts the nurse that immediate action is required?

A)   pH below 7.3

B)   Potassium of 5.0

C)   HCT of 60

D)   Pa O2 of 79%

The correct answer is C: HCT of 60

72. The nurse is preparing the teaching plan for a group of parents about risks to toddlers.

The nurse plans to explain proper communication in the event of accidental poisoning.

The nurse should plan to tell the parents to first state what substance was ingested and

then what information should be the priority for the parents to communicate?

A)  The parents' name and telephone number

B)  The currency of the immunization and allergy history of the child C) The estimated time of the accidental poisoning and a confirmation that the parents will

bring the containers of the ingested substance

D) The affected child’s age and weight

The correct answer is D: The affected child'’s age and weight 73. A 2 year-old child is brought to the health care provider’s office with a chief

complaint of mild diarrhea for 2 days. Nutritional counseling by the nurse should include which statement?

A)  Place the child on clear liquids and gelatin for 24 hours

B)  Continue with the regular diet and include oral rehydration fluids

C)  Give bananas, apples, rice and toast as tolerated

D)  Place NPO for 24 hours, then rehydrate with milk and water The correct answer is B: Continue with the regular diet and include oral rehydration fluids

74. The nurse is teaching an elderly client how to use MDI’s (multi-dose inhalers). The

nurse is concerned that the client is unable to coordinate the release of the medication

with the inhalation phase. What is the nurse’s best recommendation to improve delivery of the medication?

A)   Nebulized treatments for home care

B)   Adding a spacer device to the MDI canister

C)   Asking a family member to assist the client with the MDI

D)   Request a visiting nurse to follow the client at home

The correct answer is B: Adding a spacer device to the MDI canister 75. Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students?

A)   Scratching the head more than usual

B)   Flakes evident on a student’s shoulders

C)   Oval pattern occipital hair loss

D)   Whitish oval specks sticking to the hair

The correct answer is D: Whitish oval specks sticking to the hair 76. When parents call the emergency room to report that a toddler has swallowed drain

cleaner, the nurse instructs them to call for emergency transport to the hospital. While waiting for an ambulance,

the nurse would suggest for the parents to give sips of which substance? A) Tea

B)   Water

C)   Milk

D)   Soda

The correct answer is B: Water

77. A client is scheduled for an IVP (Intravenous Pyelogram). Which of the following

data from the client’s history indicate a potential hazard for this test?

A)   Reflex incontinence

B)   Allergic to shellfish

C)   Claustrophobia

D)   Hypertension

The correct answer is B: Allergic to shellfish

78. The nurse is preparing a handout on infant feeding to be distributed to families

visiting the clinic. Which notation should be included in the teaching materials?

A)  Solid foods are introduced 1 at a time beginning with cereal

B)  Finely ground meat should be started early to provide iron

C)  Egg white is added early to increase protein intake

D)  Solid foods should be mixed with formula in a bottle The correct answer is A: Solid foods are introduced 1 at a time beginning with cereal

79. The nurse is caring for a client with sickle cell disease who is scheduled to receive a

unit of packed red blood cells. Which of the following is an appropriate action for the nurse when administering the infusion?

A)  Storing the packed red cells in the medicine refrigerator while starting IV

B)  Slow the rate of infusion if the client develops fever or chills

C)  Limit the infusion time of each of the unit to a maximum of 4 hours

D)  Assess vital signs every 15 minutes throughout the entire infusion The correct answer is C: Limit the infusion time of each of the unit to a maximum of four hours

80. A client with a documented pulmonary embolism has the following arterial blood

gases: PO2 - 70 mm hg, PCO2 - 32 mm hg, pH - 7.45, SaO2 - 87%,

HCO3 - 22. Based on this data, what is the first nursing action?

A)   Review other lab data

B)   Notify the health care provider

C)   Administer oxygen

D)   Calm the client

The correct answer is C: Administer oxygen

81. A client diagnosed with hepatitis C discusses his health history with the admitting

nurse. The nurse should recognize which statement by the client as the most important?

A)   I got back from Central America a few weeks ago.

B)   I had the best raw oysters last week.

C)   I have many different sex partners.

D)   I had a blood transfusion 15 years ago.

The correct answer is D: I had a blood transfusion 82. A client is recovering from a thyroidectomy. While monitoring the client’s initial post

operative condition, which of the following should the nurse report immediately? A) Tetany and paresthesia

B)   Mild stridor and hoarseness

C)   Irritability and insomnia

D)   Headache and nausea

The correct answer is A: Tetany and paresthesia

83. A client is admitted with a right upper lobe infiltrate and to rule out tuberculosis. The

most appropriate action by the nurse to protect the self would be which of these?

A)   Negative room ventilation

B)   Face mask with sheild

C)   Particulate respirator mask

D)   Airborne precautions

The correct answer is C: Particulate respirator mask

84. A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be essential for the nurse to include at the change of shift report?

A)  The client lost 2 pounds in 24 hours

B)  The client’s potassium level is 4 mEq/liter.

C)  The client’s urine output was 1500 cc in 5 hours

D)  The client is to receive another dose of Lasix at 10 PM The correct answer is C: The client’s urine output was 1500 cc in five hours

85. The nurse is caring for a client with a colostomy. During a teaching session, the nurse

recommends that the pouch be emptied

A)   When it is 1/3 to 1/2 full

B)   Prior to meals

C)   After each fecal elimination

D)   At the same time each day

The correct answer is A: When it is 1/3 to 1/2 full

86. Lactulose (Chronulac) has been prescribed for a client with advanced liver disease.

Which of the following assessments would the nurse use to evaluate the effectiveness of this treatment?

A)   An increase in appetite

B)   A decrease in fluid retention

C)   A decrease in lethargy

D)   A reduction in jaundice

The correct answer is C: A decrease in lethargy

87. The mother of a 3 month-old infant tells the nurse that she wants to change from

formula to whole milk and add cereal and meats to the diet. What should be emphasized as the nurse teaches about infant nutrition? A) Solid foods should be introduced at 3-4 months

B)  Whole milk is difficult for a young infant to digest

C)  Fluoridated tap water should be used to dilute milk

D)  Supplemental apple juice can be used between feedings The correct answer is B: Whole milk is difficult for a young infant to digest

88. The nurse is assessing a 55 year-old female client who is scheduled for abdominal

surgery. Which of the following information would indicate that the client is at risk for thrombus formation in the post-operative period?

A)   Estrogen replacement therapy

B)   10% less than ideal body weight

C)   Hypersensitivity to heparin

D)   History of hepatitis

The correct answer is A: Estrogen replacement therapy

89. The nurse is planning discharge for a 90 year-old client with musculoskeletal

weakness. Which intervention should be included in the plan and would be most effective for the prevention of falls? A) Place nightlight in the bedroom

B)   Wear eyeglasses at all times

C)   Install grab bars in the bathroom

D)   Teach muscle strengthening exercises

The correct answer is A: Place nightlight in the bedroom

90. An 8 year-old client is admitted to the hospital for surgery. The child’s parent reports

the following allergies. Of these allergies which one should all health care personnel be aware of? A) Shellfish

B)   Molds

C)   Balloons

D)   Perfumed soap

The correct answer is C: Balloons

91. The nurse is caring for a client who is post-op following a thoracotomy. The client

has 2 chest tubes in place, connected to 1 chest drain. The nursing assessment reveals bubbling in the water

seal chamber when the client coughs. What is the most appropriate nursing action?

A)  Clamp the chest tube

B)  Call the surgeon immediately

C)  Continue to monitor the client to see if the bubbling increases D) Instruct the client to try to avoid coughing

The correct answer is C: Continue to monitor the client to see if the bubbling increases

92. The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir

(Zovirax) for a Herpes Simplex Virus type 2 infection. Which of these instructions should the nurse give the client?

A)  Complete the entire course of the medication for an effective cure

B)  Begin treatment with acyclovir at the onset of symptoms of recurrence

C)  Stop treatment if she thinks she may be pregnant to prevent birth defects

D)  Continue to take prophylactic doses for at least 5 years after the diagnosis

The correct answer is B: Begin treatment with acyclovir at the onset of symptoms of recurrence

93. An 8 year-old child is hospitalized during the edema phase of minimal change

nephrotic syndrome. The nurse is assisting in choosing the lunch menu. Which menu

is the best choice?

A)   Bologna sandwich, pudding, milk

B)   Frankfurter, baked potato, milk

C)   Chicken strips, corn on the cob, milk

D)   Grilled cheese sandwich, apple, milk

The correct answer is C: Chicken strips, corn on the cob, milk

94. The nurse is teaching parents about accidental poisoning in children. Which point should be emphasized?

A)  Call the Poison Control Center once the situation is identified

B)  Empty the child’s mouth in any case of possible poisoning

C)  Have the child move minimally if a toxic substance was inhaled

D)  Do not induce vomiting if the poison is a hydrocarbon The correct answer is B: Empty the child'’s mouth in any case of possible poisoning

95. Which of the following findings contraindicate the use of haloperidol (Haldol) and warrant withholding the dose? A) Drowsiness, lethargy, and inactivity

B)   Dry mouth, nasal congestion, and blurred vision

C)   Rash, blood dyscrasias, severe depression

D)   Hyperglycemia, weight gain, and edema

The correct answer is C: Rash, blood dyscrasias, severe depression

96. The nurse is planning care for a 14 year-old client returning from scoliosis corrective

surgery. Which of the following actions should receive priority in the plan?

A)  Antibiotic therapy for 10 days

B)  Teach client isometric exercises for legs

C)  Assess movement and sensation of extremities

D)  Assist to stand up at bedside within the first 24 hours The correct answer is C: Assess movement and sensation of extremities

97. A 3 year-old child diagnosed as having celiac disease attends a day care center. Which of the following would be an appropriate snack?

A)  Cheesecrackers

B)  Peanut butter sandwich C) Potato chips

D) Vanilla cookies

The correct answer is C: Potato chips

98. A client with moderate persistent asthma is admitted for a minor surgical procedure.

On admission  thepeak flow meteris measured at 480liters/minute.

Post- operatively the client is complaining of chest tightness. The peak flow has dropped  to  200liters/minute. What should the nurse do first?

A)   Notify the health care provider

B)   Administer the PRN dose of Albuterol

C)   Apply oxygen at 2 liters per nasal cannula

D)   Repeat the peak flow reading in 30 minutes

The correct answer is B: Administer the PRN dose of Albuterol 99. What finding signifies that children have attained the stage of concrete operations (Piaget)?

A)   Explores the environment with the use of sight and movement

B)   Thinks in mental images or word pictures

C)   Makes the moral judgement that “stealing is wrong”

D)   Reasons that homework is time-consuming yet necessary

The correct answer is C: Makes the moral judgment that

“stealing is wrong”

100. The nurse is caring for a 17 month-old with acetaminophen poisoning. Which of the following lab reports should the nurse review first? A) Protime (PT) and partial thromboplastin time (PTT)

B)   Red blood cell and white blood cell counts

C)   Blood urea nitrogen and creatinine clearance

D)   Liver enzymes (AST and ALT)

The correct answer is D: Liver enzymes (AST and ALT) 101. The nurse is teaching parents about diet for a 4 month-old infant with gastroenteritis

and mild dehydration. In addition to oral rehydration fluids, the diet should include A) Formula or breast milk

B)   Broth and tea

C)   Rice cereal and apple juice

D)   Gelatin and ginger ale

The correct answer is A: Formula or breast milk

102. The nurse instructs the client taking dexamethasone

(Decadron) to take it with food or milk. What is the physiological basis for this instruction?

A)   Retards pepsin production

B)   Stimulates hydrochloric acid production

C)   Slows stomach emptying time

D)   Decreases production of hydrochloric acid

The correct answer is B: Stimulates hydrochloric acid production 103. The nurse is planning care for a 3 month-old infant immediately postoperative

following placement of a ventriculoperitoneal shunt for hydrocephalus. The nurse needs to

A)   Assess for abdominal distention

B)   Maintain infant in an upright position

C)   Begin formula feedings when infant is alert

D)   Pump the shunt to assess for proper function

The correct answer is A: Assess for abdominal distention

104. The mother of a 2 year-old hospitalized child asks the nurse’s advice about the

child’s screaming every time the mother gets ready to leave the hospital room. What is the best response by the nurse?

A)  “I think you or your partner needs to stay with the child while in the hospital.”

B)  “Oh, that behavior will stop in a few days.”

C)  “Keep in mind that for the age this is a normal response to being in the hospital.”

D)  “You might want to “sneak out” of the room once the child falls asleep.” The correct answer is C: “Keep in mind that for the age this is a normal response to being in the hospital.”

105. When caring for a client receiving warfarin sodium

(Coumadin), which lab test

would the nurse monitor to determine therapeutic reponse to the drug?

A)   Bleeding time

B)   Coagulation time

C)   Prothrombin time

D)   Partial thromboplastin time

The correct answer is C: Prothrombin time

106. The nurse is caring for a 4 year-old 2 hours after tonsillectomy and adenoidectomy.

Which of the following assessments must be reported immediately?

A)   Vomiting of dark emesis

B)   Complaints of throat pain

C)   Apical heart rate of 110

D)   Increased restlessness

The correct answer is D: Increased restlessness

107. The nurse admits a 7 year-old to the emergency room after a leg injury. The x-rays

show a femur fracture near the epiphysis. The parents ask what will be the outcome of this injury. The appropriate response by the nurse should be which of these statements?

A)  “The injury is expected to heal quickly because of thin periosteum.”

B)  “In some instances the result is a retarded bone growth.”

C)  “Bone growth is stimulated in the affected leg.”

D)  “This type of injury shows more rapid union than that of younger children.”

The correct answer is B: “In some instances the result is a retarded bone growth.”

108. A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care.

During a home visit the nurse observes the client smacking her lips alternately with grinding her teeth. The nurse recognizes this assessment finding as what?

A)   Dystonia

B)   Akathesia

C)   Brady dysknesia

D)   Tardive dyskinesia

The correct answer is D: Tardive dyskinesia

109. During the check up of a 2 month-old infant at a well baby clinic, the mother

expresses concern to the nurse because a flat pink birthmark on the baby’s forehead and

eyelid has not gone away. What is an appropriate response by the nurse?

A)  “Mongolian spots are a normal finding in dark-skinned children.”

B)  “Port wine stains are often associated with other malformations.”

C)  “Telangiectatic nevi are normal and will disappear as the baby grows.”

D)  “The child is too young for consideration of surgical removal of these at this time.”

The correct answer is C: Telangiectatic nevi are normal and will disappear as the baby grows

110. A client has returned to the unit following a renal biopsy.

Which of the following nursing interventions is appropriate? A) Ambulate the client 4 hours after procedure

B)   Maintain client on NPO status for 24 hours

C)   Monitor vital signs

D)   Changedressing every 8 hours

The correct answer is C: Monitor vital signs

111. A client has been admitted with a fractured femur and has been placed in skeletal

traction. Which of the following nursing interventions should receive priority?

A)  Maintaining proper body alignment

B)  Frequent neurovascular assessments of the affected leg

C)  Inspection of pin sites for evidence of drainage or inflammation D) Applying an over-bed trapeze to assist the client with movement in bed The correct answer is B: Frequent neurovascular assessments of the affected leg

112. The nurse is teaching a client newly diagnosed with asthma how to use the metereddose

inhaler (MDI). The client asks when they will know the canister is empty. The best

response

is

A)   Drop the canister in water to observe floating

B)   Estimate how many doses are usually in the canister

C)   Count the number of doses as the inhaler is used

D)   Shake the canister to detect any fluid movement

The correct answer is A: Drop the canister in water to observe floating

113. While teaching the family of a child who will take phenytoin

(Dilantin) regularly for

seizure control, it is most important for the nurse to teach them about which of the following actions?

A)   Maintain good oral hygiene and dental care

B)   Omit medication if the child is seizure free

C)   Administer acetaminophen to promote sleep

D)   Serve a diet that is high in iron

The correct answer is A: Maintain good oral hygiene and dental care

114. A 7 month pregnant woman is admitted with complaints of painless vaginal bleeding

over several hours. The nurse should prepare the client for an immediate

A)   Non stress test

B)   Abdominal ultrasound

C)   Pelvic exam

D)   X-ray of abdomen

The correct answer is B: Abdominal ultrasound

115. The nurse is assessing a 17 year-old female client with bulimia. Which of the following laboratory reports would the nurse anticipate?

A)   Increased serum glucose

B)   Decreased albumin

C)   Decreased potassium

D)   Increased sodium retention

The correct answer is C: Decreased potassium

116. An 80 year-old client on digitalis (Lanoxin) reports nausea, vomiting, abdominal

cramps and halo vision. Which of the following laboratory results should the nurse analyze first? A) Potassium levels

B)   Blood pH

C)   Magnesium levels

D)   Blood urea nitrogen

The correct answer is A: Potassium levels

117. The nurse caring for a 9 year-old child with a fractured femur is told that a

medication error occurred. The child received twice the ordered dose of morphine an hour ago. Which nursing diagnosis is a priority at this time? A) Risk for fluid volume deficit related to morphine overdose

B) Decreased gastrointestinal mobility related to mucosal irritation C) Ineffective breathing patterns related to central nervous system depression

D) Altered nutrition related to inability to control nausea and vomiting The correct answer is C: Ineffective breathing patterns related to central nervous system depression

118. The nurse notes that a 2 year-old child recovering from a tonsillectomy has an

temperature of 98.2 degrees Fahrenheit at 8:00 AM. At 10:00 AM the child’s mother

reports that the child “feels very

warm” to touch. The first action by the nurse should be to

A)   Reassure the mother that this is normal

B)   Offer the child cold oral fluids

C)   Reassess the child’s temperature

D)   Administer the prescribed acetaminophen

The correct answer is C: Reassess the child'’s temperature 119. The nurse is teaching a newly diagnosed asthma client on how to use a peak flow

meter. The nurse explains that this should be used to

A)   Determine oxygen saturation

B)   Measure forced expiratory volume

C)   Monitor atmosphere for presence of allergens

D)   Provide metered doses for inhaled bronchodilator

The correct answer is B: Measure forced expiratory volume

120. The nurse is performing a pre-kindergarten physical on a 5 year old. The last series

of vaccines will be administered. What is the preferred site for injection by the nurse?

A)   Vastus intermedius

B)   Gluteus rainlinus

C)   Vastus lateralis

D)   DorsogluteaI

The correct answer is C: Vastus lateralis

121. A couple experienced the loss of a 7 month-old fetus. In planning for discharge, what should the nurse emphasize?

A)  To discuss feelings with each other and use support persons

B)  To focus on the other healthy children and move through the loss

C)  To seek causes for the fetal death and come to some safe conclusion

D)  To plan for another pregnancy within 2 years and maintain physical health

The correct answer is A: To discuss feelings with each other and use support persons

122. The parents of a 4 year-old hospitalized child tell the nurse,

“We are leaving now

and will be back at 6 PM.” A few hours later the child asks the nurse when the parents will come again. What is the best response by the nurse?

A)   “They will be back right after supper.”

B)   “In about 2 hours, you will see them.”

C)   “After you play awhile, they will be here.”

D)   “When the clock hands are on 6 and 12.”

The correct answer is A: “They will be back right after supper.”

123. The nurse is providing instructions for a client with asthma.

Which of the following should the client monitor on a daily basis?

A)   Respiratory rate

B)   Peak air flow volumes

C)   Pulse oximetry

D)   Skin color

The correct answer is B: Peak air flow volumes

124. Therapeutic nurse-client interaction occurs when the nurse

A)   Assists the client to clarify the meaning of what the client has said

B)   Interprets the client’s covert communication

C)   Praises the client for appropriate feelings and behavior

D)   Advises the client on ways to resolve problems

The correct answer is A: Assists the client to clarify the meaning of what the client has said

125. A 14 month-old child ingested half a bottle of aspirin tablets. Which of the following would the nurse expect to see in the child?

A)   Hypothermia

B)   Edema

C)   Dyspnea

D)   Epistaxis

The correct answer is D: Epistaxis

126. The nurse is caring for a client with a distal tibia fracture. The client has had a

closed reduction and application of a toe to groin cast. 36 hours after surgery, the client

suddenly becomes confused, short of breath and spikes a temperature of 103 degrees

Fahrenheit. The first assessment the nurse should perform is

A)   Orientation to time, place and person

B)   Pulse oximetry

C)   Circulation to casted extremity

D)   Blood pressure

The correct answer is B: Pulse oximetry

127. Which nursing intervention will be most effective in helping a withdrawn client to develop relationship skills?

A) Offer the client frequent opportunities to interact with 1 person B) Provide the client with frequent opportunities to interact with other clients

C)  Assist the client to analyze the meaning of the withdrawn behavior

D)  Discuss with the client the focus that other clients have similar problems

The correct answer is A: Offer the client frequent opportunities to interact with one person

128. The nurse is assessing a client with a Stage 2 skin ulcer. Which of the following treatments is most effective to promote healing?

A)   Covering the wound with a dry dressing

B)   Using hydrogen peroxide soaks

C)   Leaving the area open to dry

D)   Applying a hydrocolloid or foam dressing

The correct answer is D: Applying a hydrocolloid or foam dressing 129. A female client is admitted for a breast biopsy. She says, tearfully to the nurse, “If

this turns out to be cancer and I have to have my breast removed, my partner will never

come near me.” The nurse’s best response would be which of these statements?

A)  “I hear you saying that you have a fear for the loss of love.”

B)  “You sound concerned that your partner will reject you.”

C)  “Are you wondering about the effects on your sexuality?”

D)  “Are you worried that the surgery will change you?” The correct answer is D: “Are you worried that the surgery will change you?”

130. When teaching suicide prevention to the parents of a 15 year-old who recently

attempted suicide, the nurse describes the following behavioral cue

A)   Angry outbursts at significant others

B)   Fear of being left alone

C)   Giving away valued personal items

D)   Experiencing the loss of a boyfriend

The correct answer is C: Giving away valued personal items 131. The nurse is caring for a 4 year-old admitted after receiving burns to more than 50%

of his body. Which laboratory data should be reviewed by the nurse as a priority in the first 24 hours? A) Blood urea nitrogen

B)   Hematocrit

C)   Blood glucose

D)   White blood count

The correct answer is A: Blood urea nitrogen

132. The nurse is assigned to care for a client who had a myocardial infarction (MI) 2 days ago. The client has many questions about this condition. What area is a priority for the nurse to discuss at this time? A) Daily needs and concerns

B)   The overview cardiac rehabilitation

C)   Medication and diet guideline

D)   Activity and rest guidelines

The correct answer is A: Daily needs and concerns

133. The nurse is preparing a client with a deep vein thrombosis

(DVT) for a Venous

Doppler evaluation. Which of the following would be necessary for preparing the client

for this test?

A)   Client should be NPO after midnight

B)   Client should receive a sedative medication prior to the test

C)   Discontinue anti-coagulant therapy prior to the test

D)   No special preparation is necessary

The correct answer is D: No special preparation is necessary 134. While interviewing a client, the nurse notices that the client is shifting positions,

wringing her hands, and avoiding eye contact. It is important for the nurse to

A)  Ask the client what she is feeling

B)  Assess the client for auditory hallucinations

C)  Recognize the behavior as a side effect of medication D) Re-focus the discussion on a less anxiety provoking topic The correct answer is A: Ask the client what she is feeling

135. Which statement made by a client indicates to the nurse that he may have a thought disorder?

A)   “I’m so angry about this. Wait until my partner hears about this.”

B)   “I’m a little confused. What time is it?”

C)   “I can’t find my ‘mesmer’ shoes. Have you seen them?”

D)   “I’m fine. It’s my daughter who has the problem.”

The correct answer is C: “I can'’t find my ‘‘mesmer’’ shoes. Have you seen them?”

136. The nurse is observing a client with an obsessive- compulsive disorder in an inpatient setting. Which behavior is consistent with this diagnosis?

A)   Repeatedly checking that the door is locked

B)   Verbalized suspicions about thefts

C)   Preference for consistent care givers

D)   Repetitive, involuntary movements

The correct answer is A: Repeatedly checking that the door is locked

137. A young adult seeks treatment in an outpatient mental health center. The client tells

the nurse he is a government official being followed by spies. On further questioning, he reveals that his warnings must be heeded to prevent nuclear war. What is the most therapeutic approach by the nurse?

A)   Listen quietly without comment

B)   Ask for further information on the spies

C)   Confront the client on a delusion

D)   Contactthe government agency

The correct answer is A: Listen quietly without comment

138. A client is admitted to a psychiatric unit with delusions. What findings can the nurse expect?

A)   Flight of ideas and hyperactivity

B)   Suspiciousness and resistance to therapy

C)   Anorexia and hopelessness

D)   Panic and multiple physical complaints

The correct answer is B: Suspiciousness and resistance to therapy

139. A client who is a former actress enters the day room wearing a sheer nightgown,

high heels, numerous bracelets, bright red lipstick and heavily rouged cheeks. Which nursing action is the best in response to the client’s attire? A) Gently remind her that she is no longer on stage

B)  Directly assist client to her room for appropriate apparel

C)  Quietly point out to her the dress of other clients on the unit

D)  Tactfully explain appropriate clothing for the hospital The correct answer is B: Directly assist client to her room for appropriate apparel

140. Handshaking is the preferred form of touch or contact used with clients in a

psychiatric setting. The rationale behind this limited touch practice is that

A)   Some clients misconstrue hugs as an invitation to sexual advances

B)   Handshaking keeps the gesture on a professional level

C)   Refusal to touch a client denotes lack of concern

D)   Inappropriate touch often results in charges of assault and battery

The correct answer is A: Some clients misconstrue hugs as an invitation to sexual advances

141. A client with paranoid delusions stares at the nurse over a period of several days.

The client suddenly walks up to the nurse and shouts “You think you’re so perfect and

pure and good.” An appropriate response for the nurse is

A)   “Is that why you’ve been starring at me?”

B)   “You seem to be in a really bad mood.”

C)   “Perfect? I don’t quite understand.”

D)   “You are angry right now.”

The correct answer is D: “You are angry right now.” 142. An important goal in the development of a therapeutic inpatient milieu is to

A)      Provide a businesslike atmosphere where clients can work on individual goals

B)      Provide a group forum in which clients decide on unit rules, regulations, and policies

C)      Provide a testing ground for new patterns of behavior while the client takes

responsibility for his or her own actions

D)      Discourage expressions of anger because they can be disruptive to other clients

The correct answer is C: Provide a testing ground for new patterns of behavior while the

client takes responsibility for his or her own actions 143. The nurse’s primary intervention for a client who is

experiencing a panic attack is to A) Develop a trusting relationship

B)  Assist the client to describe his experience in detail

C)  Maintain safety for the client

D)  Teach the client to control his or her own behavior The correct answer is C: Maintain

safety for the client

144. Which intervention best demonstrates the nurse’s sensitivity to a 16 year old’s appropriate need for autonomy?

A)  Alertness for feelings regarding body image

B)  Allows young siblings to visit

C)  Provides opportunity to discuss concerns without presence of parents

D)  Explores his feelings of resentment to identify causes The correct answer is C: Provides opportunity to discuss concerns without presence of parents

145. A client with anorexia is hospitalized on a medical unit due to electrolyte imbalance

and cardiac dysrhythmias. Additional assessment findings that the nurse would expect to observe are

A)  Brittle hair, lanugo, amenorrhea

B)  Diarrhea, nausea, vomiting, dental erosion

C)  Hyperthermia, tachycardia, increased metabolic rate D) Excessive anxiety about symptoms

The correct answer is A: Brittle hair, lanugo, amenorrhea 146. A depressed client in an assisted living facility tells the nurse that “life isn’t worth living anymore.” What is the best response to this statement?

A)   “Come on, it is not that bad.”

B)   “Have you thought about hurting yourself?”

C)   “Did you tell that to your family?”

D)   “Think of the many positive things in life.”

The correct answer is B: “Have you thought about hurting yourself?”

147. A client, recovering from alcoholism, asks the nurse, “What can I do when I start

recognizing relapse triggers within myself?” How might the nurse best respond?

A)      “When you have the impulse to stop in a bar, contact a sober friend and talk with

him.”

B)      “Go to an AA meeting when you feel the urge to drink.” C) “It is important to exercise daily and get involved in activities that will cause you not to think about drug use.”

D) “Identify your relapse triggers as part of getting better.” The correct answer is D: “Identify your relapse triggers as part of getting better.”

148. A client was admitted to the eating disorder unit with bulimia nervosa. The nurse

assessing for a history of complications of this disorder expects

A)   Respiratory distress, dyspnea

B)   Bacterial gastrointestinal infections, over hydration

C)   Metabolic acidosis, constricted colon

D)   Dental erosion, parotid gland enlargement

The correct answer is D: Dental erosion, parotid gland enlargement 149. A nurse entering the room of a postpartum mother observes the baby lying at the

edge of the bed while the woman sits in a chair. The mother states," This is not my baby, and I do not want it." The nurse’s best response is

A)  ”This is a common occurrence after birth, but you will come to accept the baby."

B)  ”Many women have postpartum blues and need some time to love the baby."

C)  ”What a beautiful baby! Her eyes are just like yours."

D)  ”You seem upset; tell me what the pregnancy and birth were like for you."

The correct answer is D: “You seem upset; tell me what the pregnancy and birth were like for you.”

150. Which of the following times is a depressed client at highest risk for attempting suicide?

A)  Immediately after admission, during one-to-one observation

B)  7 to 14 days after initiation of antidepressant medication and psychotherapy

C)  Following an angry outburst with family

D)  When the client is removed from the security room The correct answer is B: Seven to 14 days after initiation of antidepressant medication and psychotherapy

151. A man diagnosed with epididymitis 2 days ago calls the nurse at a health clinic to

discuss the problem. What information is most important for the nurse to ask about at this time?

A)  What are you taking for pain and does it provide total relief?

B)  What does the skin on the testicles look and feel like?

C)  Do you have any questions about your care?

D)  Did you know a consequence  of  epididymitis is  infertility? The correct answer is B: What does the skin on the testicles look and feel like?

152. A client has had heart failure. Which intervention is most important for the nurse to implement prior to the initial administration of Digoxin to this client?

A)  Assess the apical pulse, counting for a full 60 seconds

B)  Take a radial pulse, counting for a full 60 seconds

C)  Use the pulse reading from the electronic blood pressure device D) Check for a pulse deficit

The correct answer is A: Assess the apical pulse, counting for a full 60 seconds

153. A client is admitted with a tentative diagnosis of congestive heart failure. Which of

the following assessments would the nurse expect to be consistent with this problem?

A)   Chest pain

B)   Pallor

C)   Inspiratory crackles

D)   Heart murmur

The correct answer is C: Inspiratory crackles

154. A nurse is providing care to a 17 year-old client in the post- operative care unit

(PACU) after an emergency appendectomy. Which finding is an early indication that the client is experiencing poor oxygenation?

A)   Abnormal breath sounds

B)   Cyanosis of the lips

C)   Increasing pulse rate

D)   Pulse oximeter reading of 92%

The correct answer is C: Increasing pulse rate

155. Which order can be associated with the prevention of atelectasis and pneumonia in a client with amyotrophic lateral sclerosis?

A)   Active and passive range of motion exercises twice a day

B)   Every 4 hours incentive spirometer

C)   Chest physiotherapy twice a day

D)   Repositioning every 2 hours around the clock

The correct answer is C: Chest physiotherapy twice a day 156. A client who was medicated with meperidine hydrochloride (Demerol) 100 mg and

hydroxyzine hydrochloride (Vistaril Intramuscular) 50 mg IM for pain related to a

fractured lower right leg 1 hour ago reports that the pain is getting worse. The nurse

should recognize that the client may be developing which complication?

A)   Acute compartment syndrome

B)   Thromboemolitic complications

C)   Fatty embolism

D)   Osteomyelitis

The correct answer is A: Acute compartment syndrome 157. The nurse is assessing an 8 month-old child with atonic cerebral palsy. Which statement from the mother supports the presence of this problem? A) When I put my finger in the left hand the baby doesn’t respond with a grasp.

B)  My baby doesn’t seem to follow when I shake toys in front of the face.

C)  When it thundered loudly last night the baby didn’t even jump. D) When I put the baby in a back lying position that’s how I find the baby. The correct answer is D: Unable to roll from 158. Which statements by the client would indicate to the nurse an understanding of the issues with end stage renal disease?

A)      I have to go at intervals for epoetin (Procrit) injections at the health department.

B)      I know I have a high risk of clot formation since my blood is thick from too many red cells.

C)      I expect to have periods of little water with voiding and then sometimes to have a lot of water.

D)      My bones will be stronger with this disease since I will have higher calcium than

 

normal.

The correct answer is A: I have to go at intervals for epoetin

(Procrit) injections at the health department.

159. The nurse is caring for a client with uncontrolled hypertension. Which findings require priority nursing action? A) Lower extremity pitting edema

B)   Rales

C)   Jugularvein distension

D)   Weakness in left arm

The correct answer is D: Weakness in left arm

160. A 2 year-old child is brought to the emergency department at 2:00 in the afternoon.

The mother states: “My child has not had a wet diaper all day.”

The nurse finds the child is pale with a heart rate of

132. What assessment data should the nurse obtain next?

A)   Status of the eyes and the tongue

B)   Description of play activity

C)   History of fluid intake

D)   Dietary patterns

The correct answer is A: Status of skin turgor