1. Which information is a priority for the RN to reinforce to an older client after intravenous pyelography?

• A) Eat a light diet for the rest of the day
• B) Rest for the next 24 hours since the preparation and the test is tiring.
• C) During waking hours drink at least 1 8-ounce glass of fluid every hour for the next 2 days
• D) Measure the urine output for the next day and immediately notify the health care provider if it should decrease.
• Correct Answer: D) Measure the urine output for the next day and immediately notify the health care provider if it should decrease.

2. A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is

• A) Difference in the intake and output
• B) Changes in the mucous membranes
• C) Skin turgor
• D) Weekly weight
• Correct Answer: D) Weekly weight

3. A client has been diagnosed with Zollinger-Ellison syndrome. Which information is most important for the nurse to reinforce with the client?

• A) It is a condition in which one or more tumors called gastrinomas form in the pancreas or in the upper part of the small intestine (duodenum)
• B) It is critical to report promptly to your health care provider any findings of peptic ulcers
• C) Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to remove any tumors
• D) With the average age at diagnosis at 50 years, the peptic ulcers may occur at unusual areas of the stomach or intestine
• Correct Answer: B) It is critical to report promptly to your health care provider any findings of peptic ulcers

4. A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client’s blood pressure is increasing. Which action should the nurse take first?

• A) Check the protein level in urine
• B) Have the client turn to the left side
• C) Take the temperature
• D) Monitor the urine output
• Correct Answer: B) Have the client turn to the left side

5. The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern?

• A) Diminished bowel sounds
• B) Loss of appetite
• C) A cold, pale lower leg
• D) Tachypnea
• Correct Answer: C) A cold, pale lower leg

6. The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to the healthcare provider?

• A) Nausea and vomiting
• B) Fever of 103 degrees Fahrenheit (39.5 degrees Celsius)
• C) Diffuse macular rash
• D) Muscle tenderness
• Correct Answer: B) Fever of 103 degrees Fahrenheit (39.5 degrees Celsius)

7. A client who had a vasectomy is in the post-recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse?

• A) Until the health care provider has determined that your ejaculate doesn’t contain sperm, continue to use another form of contraception.
• B) This procedure doesn’t impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen and no sperm are in your ejaculate.
• C) After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn’t involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in seven to ten days.
• D) The health care provider at this clinic recommends rest, ice, an athletic supporter, or over-the-counter pain medication to relieve any discomfort.
• Correct Answer: A) Until the health care provider has determined that your ejaculate doesn’t contain sperm, continue to use another form of contraception.

8. A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture?

• A) Some needles go as deep as 3 inches, depending on where they’re placed in the body and what the treatment is for. The needles usually are left in for 15 to 30 minutes.
• B) In traditional Chinese medicine, imbalances in the basic energetic flow of life — known as qi or chi — are thought to cause illness.
• C) The flow of life is believed to flow through major pathways or nerve clusters in your body.
• D) By inserting extremely fine needles into some of the over 400 acupuncture points in various combinations, it is believed that energy flow will rebalance to allow the body’s natural healing mechanisms to take over.
• Correct Answer: C) The flow of life is believed to flow through major pathways or nerve clusters in your body.

9. The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect?

• A) It is also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat, and nose), skin, and lymph nodes.
• B) In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint and abdominal pain.
• C) Kawasaki disease occurs most often in boys, children younger than age 5, and children of Hispanic descent.
• D) Initially, findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to 2 weeks.
• Correct Answer: C) Kawasaki disease occurs most often in boys, children younger than age 5, and children of Hispanic descent.

10. A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during the first 12 hours after admission?

• A) Side-lying on the left with the head elevated 10 degrees
• B) Side-lying on the left with the head elevated 35 degrees
• C) Side-lying on the right with the head elevated 10 degrees
• D) Side-lying on the right with the head elevated 35 degrees
• Correct Answer: A) Side-lying on the left with the head elevated 10 degrees

11. A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider?

• A) Light, pink urine
• B) Occasional suprapubic cramping
• C) Minimal drainage into the urinary collection bag
• D) Complaints of the feeling of pulling on the urinary catheter
• Correct Answer: C) Minimal drainage into the urinary collection bag

12. A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client’s pulse and respirations, what should be the function of the second nurse?

• A) Relieve the nurse performing CPR
• B) Go get the code cart
• C) Participate with the compressions or breathing
• D) Validate the client’s advanced directive
• Correct Answer: C) Participate with the compressions or breathing

13. The nurse assesses a 72-year-old client who was admitted for right-sided congestive heart failure. Which of the following would the nurse anticipate finding?

• A) Decreased urinary output
• B) Jugular vein distention
• C) Pleural effusion
• D) Bibasilar crackles
• Correct Answer: B) Jugular vein distention

14. A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication

• A) Can predispose to dysrhythmias
• B) May lead to oliguria
• C) May cause irritability and anxiety
• D) Sometimes alters consciousness
• Correct Answer: A) Can predispose to dysrhythmias

15. A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern?

• A) Flaccid paralysis
• B) Pupils fixed and dilated
• C) Diminished spinal reflexes
• D) Reduced sensory responses
• Correct Answer: B) Pupils fixed and dilated

16. A 14-year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of vaso-occlusive crisis. Which statements by the client would be most indicative of the etiology of this crisis?

• A) “I knew this would happen. I’ve been eating too much red meat lately.”
• B) “I really enjoyed my fishing trip yesterday. I caught 2 fish.”
• C) “I have really been working hard practicing with the debate team at school.”
• D) “I went to the doctor last week for a cold and I have gotten worse.”
• Correct Answer: D) “I went to the doctor last week for a cold and I have gotten worse.”

17. Which of these findings would the nurse more closely associate with anemia in a 10-month-old infant?

• A) Hemoglobin level of 12 g/dL
• B) Pale mucosa of the eyelids and lips
• C) Hypoactivity
• D) A heart rate between 140 to 160
• Correct Answer: B) Pale mucosa of the eyelids and lips

18. The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is

• A) Heart rate
• B) Pedal pulses
• C) Lung sounds
• D) Pupil responses
• Correct Answer: D) Pupil responses

19. Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient-controlled analgesia (PCA) with a pump?

• A) A young adult with a history of Down’s syndrome
• B) A teenager who reads at a 4th-grade level
• C) An elderly client with numerous arthritic nodules on the hands
• D) A preschooler with intermittent episodes of alertness
• Correct Answer: D) A preschooler with intermittent episodes of alertness

20. The nurse is about to assess a 6-month-old child with nonorganic failure-to-thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be

• A) Irritable and “colicky” with no attempts to pull to standing
• B) Alert, laughing and playing with a rattle, sitting with support
• C) Skin color dusky with poor skin turgor over the abdomen
• D) Pale, thin arms and legs, uninterested in surroundings
• Correct Answer: D) Pale, thin arms and legs, uninterested in surroundings

21. As the nurse is speaking with a group of teens, which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion?

• A) Mouth sores
• B) Fatigue
• C) Diarrhea
• D) Hair loss
• Correct Answer: D) Hair loss

22. While caring for a client who was admitted with a myocardial infarction (MI) 2 days ago, the nurse notes today’s temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention is to

• A) Call the health care provider immediately
• B) Administer acetaminophen as ordered as this is normal at this time
• C) Send blood, urine, and sputum for culture
• D) Increase the client’s fluid intake
• Correct Answer: B) Administer acetaminophen as ordered as this is normal at this time

23. A client is admitted for first and second-degree burns on the face, neck, anterior chest, and hands. The nurse’s priority should be

• A) Cover the areas with dry sterile dressings
• B) Assess for dyspnea or stridor
• C) Initiate intravenous therapy
• D) Administer pain medication
• Correct Answer: B) Assess for dyspnea or stridor

24. Which of these clients who call the community health clinic would the nurse ask to come in that day to be seen by the health care provider?

• A) “I started my period and now my urine has turned bright red.”
• B) “I am a diabetic and today I have been going to the bathroom every hour.”
• C) “I was started on medicine yesterday for a urine infection. Now my lower belly hurts when I go to the bathroom.”
• D) “I went to the bathroom and my urine looked very red and it didn’t hurt when I went.”
• Correct Answer: D) “I went to the bathroom and my urine looked very red and it didn’t hurt when I went.”

25. A middle-aged woman talks to the nurse in the health care provider’s office about uterine fibroids also called leiomyomas or myomas. What statement by the woman indicates more education is needed?

• A) “I am one out of every 4 women that get fibroids, and of women my age – between the 30s or 40s, fibroids occur more frequently.”
• B) “My fibroids are noncancerous tumors that grow slowly.”
• C) “My associated problems I have had are pelvic pressure and pain, urinary incontinence, frequent urination or urine retention, and constipation.”
• D) “Fibroids that cause no problems still need to be taken out.”
• Correct Answer: D) “Fibroids that cause no problems still need to be taken out.”

26. An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next?

• A) Stay with the client and observe for airway obstruction
• B) Collect pillows and pad the side rails of the bed
• C) Place an oral airway in the mouth and suction
• D) Announce a cardiac arrest, and assist with intubation
• Correct Answer: A) Stay with the client and observe for airway obstruction

27. A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs were T-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings taken now may be an early indication that the client is developing a complication of labor?

• A) FHT 168 beats/min
• B) Temperature 100 degrees Fahrenheit
• C) Cervical dilation of 4
• D) BP 138/88
• Correct Answer: A) FHT 168 beats/min

28. A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the nurse’s initial evening rounds, the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication?

• A) “I have a sharp pain in my chest when I take a breath.”
• B) “I have been coughing up foul-tasting, brown, thick sputum.”
• C) “I have been sweating all day.”
• D) “I feel hot off and on.”
• Correct Answer: B) “I have been coughing up foul-tasting, brown, thick sputum.”

29. The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal

• A) S3 ventricular gallop
• B) Apical click
• C) Systolic murmur
• D) Split S2
• Correct Answer: A) S3 ventricular gallop

30. Which of these observations made by the nurse during an excretory urogram indicates a complication?

• A) The client complains of a salty taste in the mouth when the dye is injected
• B) The client’s entire body turns a bright red color
• C) The client states “I have a feeling of getting warm.”
• D) The client gags and complains “I am getting sick.”
• Correct Answer: B) The client’s entire body turns a bright red color

31. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client?

• A) “The tube will drain fluid from your chest.”
• B) “The tube will remove excess air from your chest.”
• C) “The tube controls the amount of air that enters your chest.”
• D) “The tube will seal the hole in your lung.”
• Correct Answer: B) “The tube will remove excess air from your chest.”

32. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately?

• A) Blood urea nitrogen 50 mg/dl
• B) Hemoglobin of 10.3 mg/dl
• C) Venous blood pH 7.30
• D) Serum potassium 6 mEq/L
• Correct Answer: D) Serum potassium 6 mEq/L

33. The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse’s immediate attention?

• A) Pallor
• B) Increased temperature
• C) Dyspnea
• D) Involuntary muscle spasms
• Correct Answer: C) Dyspnea

34. The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the nurse?

• A) Breath sounds can be heard bilaterally
• B) Mist is visible in the T-Piece
• C) Pulse oximetry of 88
• D) Client is unable to speak
• Correct Answer: C) Pulse oximetry of 88

35. A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning?

• A) Drowsiness
• B) Complaint of nausea
• C) Pulse rate of 92
• D) Restlessness
• Correct Answer: D) Restlessness

36. The most effective nursing intervention to prevent atelectasis from developing in a postoperative client is to

• A) Maintain adequate hydration
• B) Assist client to turn, deep breathe, and cough
• C) Ambulate client within 12 hours
• D) Splint incision
• Correct Answer: B) Assist client to turn, deep breathe, and cough

37. When caring for a client with a post-right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote

• A) Relaxation and sleep
• B) Deep breathing and coughing
• C) Incisional healing
• D) Range of motion exercises
• Correct Answer: B) Deep breathing and coughing

38. A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first?

• A) Ask the client to cough sputum into a container
• B) Have the client take several deep breaths
• C) Provide an appropriate specimen container
• D) Assist with oral hygiene
• Correct Answer: D) Assist with oral hygiene

39. The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?

• A) Blanch nail beds for color and refill
• B) Assess for postoperative arrhythmias
• C) Auscultate for pulmonary congestion
• D) Monitor the equality of peripheral pulses
• Correct Answer: B) Assess for postoperative arrhythmias

40. A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client’s room, his oxygen is running at 6 liters per minute, his color is flushed, and his respirations are 8 per minute. What should the nurse do first?

• A) Obtain a 12-lead EKG
• B) Place client in high Fowler’s position
• C) Lower the oxygen rate
• D) Take baseline vital signs
• Correct Answer: C) Lower the oxygen rate

41. A 4-year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first?

• A) Notify the health care provider
• B) Readjust the traction
• C) Administer the ordered prn medication
• D) Reassess the foot in fifteen minutes
• Correct Answer: A) Notify the health care provider

42. The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse’s first action should be to

• A) Wrap the leg with elastic bandages
• B) Apply pressure at the bleeding site
• C) Reinforce the dressing and elevate the leg
• D) Remove the dressings and re-dress the incision
• Correct Answer: C) Reinforce the dressing and elevate the leg

43. A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take priority in planning care?

• A) Esophagitis
• B) Leukopenia
• C) Fatigue
• D) Skin irritation
• Correct Answer: B) Leukopenia

44. A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action?

• A) Clamp the chest tube
• B) Call the surgeon immediately
• C) Prepare for blood transfusion
• D) Continue to monitor the rate of drainage
• Correct Answer: D) Continue to monitor the rate of drainage

45. A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure?

• A) Increased blood pressure
• B) Increased heart rate
• C) Loss of pulse in the extremity
• D) Decreased urine output
• Correct Answer: C) Loss of pulse in the extremity

46. A 60-year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void?

• A) Have him drink several glasses of water
• B) Crede’ the bladder from the bottom to the top
• C) Assist him to stand by the side of the bed to void
• D) Wait 2 hours and have him try to void again
• Correct Answer: C) Assist him to stand by the side of the bed to void

47. The nurse is caring for a client who requires a mechanical ventilator for breathing. The high-pressure alarm goes off on the ventilator. What is the first action the nurse should perform?

• A) Disconnect the client from the ventilator and use a manual resuscitation bag
• B) Perform a quick assessment of the client’s condition
• C) Call the respiratory therapist for help
• D) Press the alarm re-set button on the ventilator
• Correct Answer: B) Perform a quick assessment of the client’s condition

48. The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test?

• A) “I can’t lie in 1 position for more than thirty minutes.”
• B) “I am allergic to shrimp.”
• C) “I suffer from claustrophobia.”
• D) “I developed a severe headache after a spinal tap.”
• Correct Answer: B) “I am allergic to shrimp.”

49. The health care provider order reads “aspirate nasogastric feeding (NG) tube every 4 hours and check pH of aspirate.” The pH of the aspirate is 10. Which action should the nurse take?

• A) Hold the tube feeding and notify the provider
• B) Administer the tube feeding as scheduled
• C) Irrigate the tube with diet cola soda
• D) Apply intermittent suction to the feeding tube
• Correct Answer: A) Hold the tube feeding and notify the provider

50. To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must

• A) Apply suction for no more than 10 seconds
• B) Maintain sterile technique
• C) Lubricate 3 to 4 inches of the catheter tip
• D) Withdraw catheter in a circular motion
• Correct Answer: A) Apply suction for no more than 10 seconds

51. An antibiotic IM injection for a 2-year-old child is ordered. The total volume of the injection equals 2.0 ml. The correct action is to

• A) Administer the medication in 2 separate injections
• B) Give the medication in the dorsal gluteal site
• C) Call to get a smaller volume ordered
• D) Check with pharmacy for a liquid form of the medication
• Correct Answer: A) Administer the medication in 2 separate injections

52. The nurse receives an order to give a client iron by deep injection. The nurse knows that the reason for this route is to

• A) Enhance absorption of the medication
• B) Ensure that the entire dose of medication is given
• C) Provide more even distribution of the drug
• D) Prevent the drug from tissue irritation
• Correct Answer: D) Prevent the drug from tissue irritation

53. A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug?

• A) Diaphoresis with decreased urinary output
• B) Increased heart rate with increased respirations
• C) Improved respiratory status and increased urinary output
• D) Decreased chest pain and decreased blood pressure
• Correct Answer: C) Improved respiratory status and increased urinary output

54. While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse’s best response?

• A) “As you urinate more, you will need less medication to control fluid.”
• B) “You will have to take this medication for about a year.”
• C) “The medication must be continued so the fluid problem is controlled.”
• D) “Please talk to your health care provider about medications and treatments.”
• Correct Answer: C) “The medication must be continued so the fluid problem is controlled.”

55. A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client to report?

• A) Change in libido, breast enlargement
• B) Sore throat, fever
• C) Abdominal pain, nausea, diarrhea
• D) Dyspnea, nasal congestion
• Correct Answer: B) Sore throat, fever

56. A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic?

• A) Bruising at the operative site
• B) Elevated heart rate
• C) Decreased platelet count
• D) No bowel movement for 3 days
• Correct Answer: D) No bowel movement for 3 days

57. A client is being maintained on heparin therapy for deep vein thrombosis. The nurse must closely monitor which of the following laboratory values?

• A) Bleeding time
• B) Platelet count
• C) Activated PTT
• D) Clotting time
• Correct Answer: C) Activated PTT

58. A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate?

• A) Pulverize all medications to a powdery condition
• B) Squeeze the tube before using it to break up stagnant liquids
• C) Cleanse the skin around the tube daily with hydrogen peroxide
• D) Flush adequately with water before and after using the tube
• Correct Answer: D) Flush adequately with water before and after using the tube

59. The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the following statements suggests that the teaching was effective?

• A) “We will call the health care provider if the child develops acne.”
• B) “Our child should brush and floss carefully after every meal.”
• C) “We will skip the next dose if vomiting or fever occur.”
• D) “When our child is seizure-free for 6 months, we can stop the medication.”
• Correct Answer: B) “Our child should brush and floss carefully after every meal.”

60. Although non-steroidal anti-inflammatory drugs such as ibuprofen (Motrin) are beneficial in managing arthritis pain, the nurse should caution clients about which of the following common side effects?

• A) Urinary incontinence
• B) Constipation
• C) Nystagmus
• D) Occult bleeding
• Correct Answer: D) Occult bleeding

61. The nurse is caring for a client with clinical depression who is receiving an MAO inhibitor. When providing instructions about precautions with this medication, which action should the nurse stress to the client as important?

• A) Avoid chocolate and cheese
• B) Take frequent naps
• C) Take the medication with milk
• D) Avoid walking without assistance
• Correct Answer: A) Avoid chocolate and cheese

62. A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse?

• A) Cut the child’s hair short to remove the nits
• B) Apply warm soaks to the head twice daily
• C) Wash the child’s linen and clothing in a bleach solution
• D) Application of pediculicides
• Correct Answer: D) Application of pediculicides

63. The nurse is teaching a client about precautions with Coumadin therapy. The client should be instructed to avoid which over-the-counter medication?

• A) Non-steroidal anti-inflammatory drugs
• B) Cough medicines with guaifenesin
• C) Histamine blockers
• D) Laxatives containing magnesium salts
• Correct Answer: A) Non-steroidal anti-inflammatory drugs

64. A client diagnosed with cirrhosis of the liver and ascites is receiving Spironolactone (Aldactone). The nurse understands that this medication spares elimination of which element?

• A) Sodium
• B) Potassium
• C) Phosphate
• D) Albumin
• Correct Answer: B) Potassium

65. The nurse is caring for a client receiving a blood transfusion who develops urticaria one-half hour after the transfusion has begun. What is the first action the nurse should take?

• A) Stop the infusion
• B) Slow the rate of infusion
• C) Take vital signs and observe for further deterioration
• D) Administer Benadryl and continue the infusion
• Correct Answer: A) Stop the infusion

66. Discharge instructions for a client taking alprazolam (Xanax) should include which of the following?

• A) Sedative hypnotics are effective analgesics
• B) Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares
• C) Caffeine beverages can increase the effect of sedative hypnotics
• D) Avoidance of excessive exercise and high temperature is recommended
• Correct Answer: B) Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares

67. A client has received 2 units of whole blood today following an episode of GI bleeding. Which of the following laboratory reports would the nurse monitor most closely?

• A) Bleeding time
• B) Hemoglobin and hematocrit
• C) White blood cells
• D) Platelets
• Correct Answer: B) Hemoglobin and hematocrit

68. A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin?

• A) Protamine
• B) Amicar
• C) Imferon
• D) Diltiazem
• Correct Answer: A) Protamine

69. The nurse has been teaching a client with Insulin Dependent Diabetes Mellitus. Which statement by the client indicates a need for further teaching?

• A) “I use a sliding scale to adjust regular insulin to my sugar level.”
• B) “Since my eyesight is so bad, I ask the nurse to fill several syringes.”
• C) “I keep my regular insulin bottle in the refrigerator.”
• D) “I always make sure to shake the NPH bottle hard to mix it well.”
• Correct Answer: D) “I always make sure to shake the NPH bottle hard to mix it well.”

70. Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs?

• A) Orthostatic hypotension is a common side effect
• B) Most antipsychotic drugs cause elevated blood pressure
• C) This provides information on the amount of sodium allowed in the diet
• D) It will indicate the need to institute anti-parkinsonian drugs
• Correct Answer: A) Orthostatic hypotension is a common side effect

71. The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity. Which choice indicates the client understands dietary needs?

• A) Three apricots
• B) Medium banana
• C) Navel orange
• D) Baked potato
• Correct Answer: D) Baked potato

72. An 86-year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next?

• A) Add a thickening agent to the fluids
• B) Check the client’s gag reflex
• C) Feed the client only solid foods
• D) Increase the rate of intravenous fluids
• Correct Answer: B) Check the client’s gag reflex

73. The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown?

• A) Place client in the wheelchair for four hours each day
• B) Pad the bony prominence
• C) Reposition every two hours
• D) Massage reddened bony prominence
• Correct Answer: C) Reposition every two hours

74. A nurse is assessing several clients in a long-term health care facility. Which client is at highest risk for the development of decubitus ulcers?

• A) A 79-year-old malnourished client on bed rest
• B) An obese client who uses a wheelchair
• C) A client who had 3 incontinent diarrhea stools
• D) An 80-year-old ambulatory diabetic client
• Correct Answer: A) A 79-year-old malnourished client on bed rest

75. Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse’s priority?

• A) Obtain a complete blood count
• B) Obtain a health and dietary history
• C) Refer to a provider for a physical examination
• D) Measure height and weight
• Correct Answer: B) Obtain a health and dietary history

76. After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is

• A) Abdominal x-ray
• B) Auscultation
• C) Flushing tube with saline
• D) Aspiration for gastric contents
• Correct Answer: A) Abdominal x-ray

77. A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?

• A) Allow the client to melt ice chips in the mouth
• B) Provide mints to freshen the breath
• C) Perform frequent oral care with a tooth sponge
• D) Swab the mouth with glycerin swabs
• Correct Answer: C) Perform frequent oral care with a tooth sponge

78. The nurse is instructing a 65-year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to

• A) Exercise doing weight-bearing activities
• B) Exercise to reduce weight
• C) Avoid exercise activities that increase the risk of fracture
• D) Exercise to strengthen muscles and thereby protect bones
• Correct Answer: A) Exercise doing weight-bearing activities

79. The nurse has been teaching a client with congestive heart failure about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction?

• A) Cheese sandwich with a glass of 2% milk
• B) Sliced turkey sandwich and canned pineapple
• C) Cheeseburger and baked potato
• D) Mushroom pizza and ice cream
• Correct Answer: B) Sliced turkey sandwich and canned pineapple

80. Which bed position is preferred for use with a client in an extended care facility on falls risk prevention protocol?

• A) All 4 side rails up, wheels locked, bed closest to door
• B) Lower side rails up, bed facing doorway
• C) Knees bent, head slightly elevated, bed in lowest position
• D) Bed in lowest position, wheels locked, place bed against the wall
• Correct Answer: D) Bed in lowest position, wheels locked, place bed against the wall

81. When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula

• A) Every four to six hours
• B) Continuously
• C) In a bolus
• D) Every hour
• Correct Answer: B) Continuously

82. The nurse is teaching an 87-year-old client methods for maintaining regular bowel movements. The nurse would caution the client to AVOID

• A) Glycerine suppositories
• B) Fiber supplements
• C) Laxatives
• D) Stool softeners
• Correct Answer: C) Laxatives

83. A client with diarrhea should avoid which of the following?

• A) Orange juice
• B) Tuna
• C) Eggs
• D) Macaroni
• Correct Answer: A) Orange juice

84. Which statement best describes the effects of immobility in children?

• A) Immobility prevents the progression of language and fine motor development
• B) Immobility in children has similar physical effects to those found in adults
• C) Children are more susceptible to the effects of immobility than are adults
• D) Children are likely to have prolonged immobility with subsequent complications
• Correct Answer: B) Immobility in children has similar physical effects to those found in adults

85. A nurse is providing care to a 63-year-old client with pneumonia. Which intervention promotes the client’s comfort?

• A) Increase oral fluid intake
• B) Encourage visits from family and friends
• C) Keep conversations short
• D) Monitor vital signs frequently
• Correct Answer: C) Keep conversations short

86. After a myocardial infarction, a client is placed on a sodium-restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate?

• A) 3 oz. broiled fish, 1 baked potato, 1/2 cup canned beets, 1 orange, and milk
• B) 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple
• C) A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice
• D) 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange
• Correct Answer: D) 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange

87. The nurse is caring for a 7-year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate?

• A) Decreased carbohydrates and fat
• B) Decreased sodium and potassium
• C) Increased potassium and protein
• D) Increased sodium and fluids
• Correct Answer: B) Decreased sodium and potassium

88. What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction?

• A) Presence of blood in stools
• B) Oozing liquid stool
• C) Continuous rumbling flatulence
• D) Absence of bowel movements
• Correct Answer: B) Oozing liquid stool

89. A client in a long-term care facility complains of pain. The nurse collects data about the client’s pain. The first step in pain assessment is for the nurse to

• A) Have the client identify coping methods
• B) Get the description of the location and intensity of the pain
• C) Accept the client’s report of pain
• D) Determine the client’s status of pain
• Correct Answer: C) Accept the client’s report of pain

90. An 85-year-old client complains of generalized muscle aches and pains. The first action by the nurse should be

• A) Assess the severity and location of the pain
• B) Obtain an order for an analgesic
• C) Reassure him that this is not unusual for his age
• D) Encourage him to increase his activity
• Correct Answer: A) Assess the severity and location of the pain

91. A 20-year-old client has an infected leg wound from a motorcycle accident, and the client has returned home from the hospital. The client is to keep the affected leg elevated and is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that:

• A) Visitors must wear a mask and a gown
• B) There are no special requirements for visitors of clients on contact precautions
• C) Visitors should wash their hands before and after touching the client
• D) Visitors should wear gloves when touching the client
• Correct Answer: C) Visitors should wash their hands before and after touching the client

92. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first?

• A) Institute seizure precautions
• B) Monitor neurologic status every hour
• C) Place in respiratory/secretion precautions
• D) Cefotaxime IV 50 mg/kg/day divided q6h
• Correct Answer: C) Place in respiratory/secretion precautions

93. Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls?

• A) Sensory perceptual alterations related to decreased vision
• B) Alteration in mobility related to fatigue
• C) Impaired gas exchange related to retained secretions
• D) Altered patterns of urinary elimination related to nocturia
• Correct Answer: D) Altered patterns of urinary elimination related to nocturia

94. A nurse who is reassigned to the emergency department needs to understand that gastric lavage is a priority in which situation?

• A) An infant who has been identified to have botulism
• B) A toddler who ate a number of ibuprofen tablets
• C) A preschooler who swallowed powdered plant food
• D) A school-aged child who took a handful of vitamins
• Correct Answer: A) An infant who has been identified to have botulism

95. A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to hand washing, to be implemented is which of these?

• A) Apply appropriate signs outside and inside the room
• B) Apply a mask with a shield if there is a risk of fluid splash
• C) Wear a gown to change soiled linens from incontinence
• D) Have gloves on while handling bedpans with feces
• Correct Answer: D) Have gloves on while handling bedpans with feces

96. Which of these clients with associated lab reports is a priority for the nurse to report to the public health department within the next 24 hours?

• A) An infant with a positive culture of stool for Shigella
• B) An elderly factory worker with a lab report that is positive for acid-fast bacillus smear
• C) A young adult commercial pilot with a positive histopathological examination from an induced sputum for Pneumocystis carinii
• D) A middle-aged nurse with a history of varicella-zoster virus and with crops of vesicles on an erythematous base that appear on the skin
• Correct Answer: B) An elderly factory worker with a lab report that is positive for acid-fast bacillus smear

97. A client is diagnosed with methicillin-resistant staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client?

• A) Reverse
• B) Airborne
• C) Standard precautions
• D) Contact
• Correct Answer: D) Contact

98. The school nurse is teaching the faculty the most effective methods to prevent the spread of lice in the school. The information that would be most important to include would be which of these statements?

• A) “The treatment requires reapplication in 8 to 10 days.”
• B) “Bedding and clothing can be boiled or steamed.”
• C) Children are not to share hats, scarves, and combs.
• D) Nit combs are necessary to comb out nits.
• Correct Answer: C) Children are not to share hats, scarves, and combs.

99. During the care of a client with a salmonella infection, the primary nursing intervention to limit transmission is which of these approaches?

• A) Wash hands thoroughly before and after client contact
• B) Wear gloves when in contact with body secretions
• C) Double glove when in contact with feces or vomitus
• D) Wear gloves when disposing of contaminated linens
• Correct Answer: A) Wash hands thoroughly before and after client contact

100. A nurse is reinforcing teaching with a client about compromised host precautions. The client is receiving filgrastim (Neupogen) for neutropenia. The selection of which lunch suggests the client has learned about necessary dietary changes?

• A) Grilled chicken sandwich and skim milk
• B) Roast beef, mashed potatoes, and green beans
• C) Peanut butter sandwich, banana, and iced tea
• D) Barbecue beef, baked beans, and cole slaw
• Correct Answer: B) Roast beef, mashed potatoes, and green beans

101. After an explosion at a factory, one of the workers approaches the nurse and says, “I am an unlicensed assistive personnel (UAP) at the local hospital.” Which of these tasks should the nurse assign to this worker who wants to help during the care of the wounded workers?

• A) Get temperatures
• B) Take blood pressure
• C) Palpate pulses
• D) Check alertness
• Correct Answer: C) Palpate pulses

102. Which of these clients would the nurse recommend to keep in the hospital during an internal disaster at the agency?

• A) An adolescent diagnosed with sepsis 7 days ago with vital signs maintained within low normal
• B) A middle-aged woman documented to have had an uncomplicated myocardial infarction 4 days ago
• C) An elderly man admitted 2 days ago with an acute exacerbation of ulcerative colitis
• D) A young adult in the second day of treatment for an overdose of acetaminophen
• Correct Answer: D) A young adult in the second day of treatment for an overdose of acetaminophen

103. The mother of a toddler who is being treated for pesticide poisoning asks: “Why is activated charcoal used? What does it do?” What is the nurse’s best response?

• A) “Activated charcoal decreases the systemic absorption of the poison from the stomach.”
• B) “The charcoal absorbs the poison and forms a compound that doesn’t hurt your child.”
• C) “This substance helps to get the poison out of the body by the gastrointestinal system.”
• D) “The action may bind or inactivate the toxins or irritants that are ingested by children or adults.”
• Correct Answer: B) “The charcoal absorbs the poison and forms a compound that doesn’t hurt your child.”

104. The nurse is to administer a new medication to a client. Which actions are in the best interest of the client? Verify the order for the medication. Prior to giving the medication the nurse should say

• A) “Please state your name?” Upon entering the room the nurse should ask:
• B) “What is your name? What allergies do you have?” then check the client’s name band and allergy band as the room is entered.
• C) “What is your name?” then check the client’s name band. Verify the client’s allergies on the admission sheet and order.
• D) “Verify the client’s name on the name plate outside the room then as the nurse enters the room ask the client ‘What is your first, middle and last name?'”
• Correct Answer: B) “What is your name? What allergies do you have?” then check the client’s name band and allergy band.

105. When a client is receiving total parenteral nutrition (TPN), it is essential for the nurse to assess for the presence of which of these complications?

• A) Infection and decreased blood glucose
• B) Electrolyte imbalance and respiratory distress
• C) Respiratory depression and weight loss
• D) Elevated blood glucose and infection
• Correct Answer: D) Elevated blood glucose and infection

106. A mother with an Rh-negative blood type is being discharged from the hospital with her Rh-positive infant after delivery. To prevent Rh incompatibility issues in future pregnancies, the nurse should instruct the mother to receive which of the following?

• A) MMR vaccine
• B) RhoGAM
• C) Hepatitis B vaccine
• D) Rubella vaccine
• Correct Answer: B) RhoGAM

107. A client who has been in labor for 12 hours is now 10 cm dilated and 100% effaced. The client reports feeling a strong urge to push. Which of the following actions should the nurse take?

• A) Instruct the client to begin pushing
• B) Prepare the client for delivery
• C) Encourage the client to pant through contractions
• D) Allow the client to rest between contractions
• Correct Answer: C) Encourage the client to pant through contractions

108. A nurse is caring for a client who is 2 hours postpartum. The client’s fundus is firm, 2 fingerbreadths above the umbilicus, and deviated to the right. Which of the following actions should the nurse take?

• A) Assist the client to void
• B) Massage the client’s fundus
• C) Notify the provider
• D) Encourage the client to ambulate
• Correct Answer: A) Assist the client to void

109. A client in the emergency department is diagnosed with hypovolemic shock. Which of the following fluids should the nurse anticipate administering to the client?

• A) 0.9% sodium chloride
• B) Dextrose 5% in 0.45% sodium chloride
• C) Dextrose 5% in water
• D) 0.45% sodium chloride
• Correct Answer: A) 0.9% sodium chloride

110. A nurse is reinforcing teaching with a client who is to begin taking metoprolol. Which of the following information should the nurse include?

• A) “Take the medication with food.”
• B) “Expect to experience insomnia.”
• C) “Stop taking the medication if you become dizzy.”
• D) “The medication can cause weight loss.”
• Correct Answer: A) “Take the medication with food.”

111. A nurse is caring for a client who has end-stage kidney disease and is refusing hemodialysis. Which of the following actions should the nurse take first?

• A) Encourage the client to comply with the provider’s orders
• B) Explore the client’s reasons for refusing treatment
• C) Document the client’s refusal of the treatment
• D) Notify the provider of the client’s decision
• Correct Answer: B) Explore the client’s reasons for refusing treatment

112. A nurse is reinforcing teaching with a client who is postpartum and is to receive a rubella immunization. Which of the following statements by the client indicates an understanding of the teaching?

• A) “I will receive the vaccine in my abdomen.”
• B) “I should not receive this vaccine if I am breastfeeding.”
• C) “I need a second vaccination if I become pregnant again.”
• D) “I should avoid getting pregnant for at least 1 month after receiving this vaccine.”
• Correct Answer: D) “I should avoid getting pregnant for at least 1 month after receiving this vaccine.”

113. A nurse is reviewing the medication record of a client who has rheumatoid arthritis and is receiving prednisone. Which of the following laboratory tests should the nurse plan to monitor?

• A) Serum calcium
• B) Serum amylase
• C) Serum creatinine
• D) Serum albumin
• Correct Answer: A) Serum calcium

114. A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). Which of the following findings should the nurse expect?

• A) Decreased anteroposterior chest diameter
• B) HCO3- 25 mEq/L
• C) pH 7.38
• D) PaO2 50 mm Hg
• Correct Answer: D) PaO2 50 mm Hg

115. A nurse is reinforcing teaching about foot care with a client who has diabetes mellitus. Which of the following information should the nurse include?

• A) “Soak your feet daily.”
• B) “Wear open-toe shoes.”
• C) “Apply lotion between your toes.”
• D) “Test water temperature with your wrist.”
• Correct Answer: D) “Test water temperature with your wrist.”

116. A nurse is assisting in the development of a discharge plan for a client who has a new ileostomy. Which of the following actions should the nurse take?

• A) Discourage the client from consuming high-fiber foods
• B) Instruct the client to limit fluid intake to 1,000 mL/day
• C) Advise the client to take a laxative if no bowel movement occurs daily
• D) Inform the client that the ileostomy pouch should be changed every 24 hours
• Correct Answer: A) Discourage the client from consuming high-fiber foods

117. A nurse is preparing to administer medications to a group of clients. Which of the following actions should the nurse take to demonstrate the ethical principle of veracity?

• A) Offer the medication at the time the client prefers
• B) Provide medications with safety and competence
• C) Give the medication to the client after identifying them
• D) Teach the client about potential adverse effects of the medication
• Correct Answer: D) Teach the client about potential adverse effects of the medication

118. A nurse is preparing to administer potassium chloride 40 mEq to a client who has hypokalemia. Which of the following actions should the nurse take?

• A) Give the medication as an IV bolus
• B) Infuse the medication through a peripheral vein at 30 mL/hr
• C) Administer the medication through an infusion pump
• D) Add the medication to an IV bag and infuse over 15 min
• Correct Answer: C) Administer the medication through an infusion pump

119. A nurse is reinforcing teaching with a client who has tuberculosis and a new prescription for rifampin. Which of the following information should the nurse include?

• A) “Your medication can decrease the effectiveness of oral contraceptives.”
• B) “This medication can cause a decrease in your white blood cell count.”
• C) “Your urine and other secretions might turn green.”
• D) “This medication can cause swelling of the lymph nodes.”
• Correct Answer: A) “Your medication can decrease the effectiveness of oral contraceptives.”

120. A nurse is reinforcing teaching with a client who is receiving radiation therapy for breast cancer. Which of the following instructions should the nurse include?

• A) “Use a heating pad on the area to alleviate discomfort.”
• B) “Apply lotion to the irradiated area twice daily.”
• C) “Wear a loose-fitting bra.”
• D) “Limit sun exposure to the irradiated area to 1 hour per day.”
• Correct Answer: C) “Wear a loose-fitting bra.”

121. A nurse is caring for a client who has heart failure and is taking digoxin. Which of the following laboratory results should the nurse report to the provider?

• A) Sodium 136 mEq/L
• B) Magnesium 1.6 mEq/L
• C) Calcium 9.6 mg/dL
• D) Potassium 2.8 mEq/L
• Correct Answer: D) Potassium 2.8 mEq/L

122. A nurse is caring for a client who is 2 hours postoperative following a thyroidectomy. Which of the following manifestations should the nurse report to the provider?

• A) Negative Chvostek’s sign
• B) Hoarseness
• C) Productive cough
• D) Hypothermia
• Correct Answer: B) Hoarseness

123. The nurse is caring for several hospitalized children with the following diagnoses. Which disorder is likely to result in metabolic acidosis?

• A) Severe diarrhea for 24 hours
• B) Nausea with anorexia
• C) Alternating constipation and diarrhea
• D) Vomiting for over 48 hours
• Correct Answer: A) Severe diarrhea for 24 hours

124. The nurse is assigned to care for a client newly diagnosed with angina. As part of discharge teaching, it is important to remind the client to remove the nitroglycerine patch after 12 hours in order to prevent what condition?

• A) Skin irritation
• B) Drug tolerance
• C) Severe headaches
• D) Postural hypotension
• Correct Answer: B) Drug tolerance

125. What is the major developmental task that the mother must accomplish during the first trimester of pregnancy?

• A) Acceptance of the pregnancy
• B) Acceptance of the termination of the pregnancy
• C) Acceptance of the fetus as a separate and unique being
• D) Satisfactory resolution of fears related to giving birth
• Correct Answer: A) Acceptance of the pregnancy

126. During the two-month well-baby visit, the mother complains that formula seems to stick to her baby’s mouth and tongue. Which of the following would provide the most valuable nursing assessment?

• A) Inspect the baby’s mouth and throat
• B) Obtain cultures of the mucous membranes
• C) Flush both sides of the mouth with normal saline
• D) Use a soft cloth to attempt to remove the patches
• Correct Answer: D) Use a soft cloth to attempt to remove the patches

127. After successful alcohol detoxification, a client remarked to a friend, “I’ve tried to stop drinking but I just can’t, I can’t even work without having a drink.” The client’s belief that he needs alcohol indicates his dependence is primarily

• A) Psychological
• B) Physical
• C) Biological
• D) Social-cultural
• Correct Answer: A) Psychological

128. A new nurse manager is responsible for interviewing applicants for a staff nurse position. Which interview strategy would be the best approach?

• A) Vary the interview style for each candidate to learn different techniques
• B) Use simple questions requiring “yes” and “no” answers to gain definitive information
• C) Obtain an interview guide from human resources for consistency in interviewing each candidate
• D) Ask personal information of each applicant to assure meeting of job demands
• Correct Answer: C) Obtain an interview guide from human resources for consistency in interviewing each candidate

129. A client who is 12 hours post-op becomes confused and says: “Giant sharks are swimming across the ceiling.” Which assessment is necessary to adequately identify the source of this client’s behavior?

• A) Cardiac rhythm strip
• B) Pupillary response
• C) Pulse oximetry
• D) Peripheral glucose stick
• Correct Answer: C) Pulse oximetry

130. A client returns from surgery after an open reduction of a femur fracture. There is a small bloodstain on the cast. Four hours later, the nurse observes that the stain has doubled in size. What is the best action for the nurse to take?

• A) Call the health care provider
• B) Access the site by cutting a window in the cast
• C) Record the findings in the nurse’s notes only
• D) Outline the spot with a pencil and note the time and date on the cast
• Correct Answer: D) Outline the spot with a pencil and note the time and date on the cast

131. A nurse assessing the newborn of a mother with diabetes understands that hypoglycemia is related to what pathophysiological process?

• A) Disruption of fetal glucose supply
• B) Pancreatic insufficiency
• C) Maternal insulin dependency
• D) Reduced glycogen reserves
• Correct Answer: A) Disruption of fetal glucose supply

132. The nurse is teaching a parent about side effects of routine immunizations. Which of the following must be reported immediately?

• A) Irritability
• B) Slight edema at site
• C) Local tenderness
• D) Temperature of 102.5 F
• Correct Answer: D) Temperature of 102.5 F

133. The parents of a toddler ask the nurse how long their child will have to sit in a car seat while in the automobile. What is the nurse’s best response to the parents?

• A) “Your child must use a car seat until he weighs at least 40 pounds."
• B) The child must be 5 years of age to use a regular seat belt.
• C) “Your child must reach a height of 50 inches to sit in a seat belt."
• D) “Your child must use a car seat until he weighs at least 60 pounds."
• Correct Answer: A) “Your child must use a car seat until he weighs at least 40 pounds."

134. The nurse is caring for a client newly diagnosed with angina. Which information should the nurse reinforce about the client’s medication therapy?

• A) Place nitroglycerin patch on the chest wall for 24 hours daily
• B) Nitroglycerin tablets should be taken before physical exertion
• C) Rotate nitroglycerin patches to prevent skin irritation
• D) Store nitroglycerin tablets in a well-lit area to ensure potency
• Correct Answer: C) Rotate nitroglycerin patches to prevent skin irritation

135. A client has an order for digoxin (Lanoxin) 0.25 mg daily. What assessment should the nurse perform before administering the medication?

• A) Apical pulse
• B) Blood pressure
• C) Respiratory rate
• D) Temperature
• Correct Answer: A) Apical pulse

136. The nurse is caring for a client with chronic renal failure who is receiving hemodialysis. The client asks the nurse about fluid restrictions. Which response by the nurse is best?

• A) “You can drink as much as you want.”
• B) “Your fluid intake should be limited to 1,000 to 1,500 mL per day.”
• C) “You should drink only when you are thirsty.”
• D) “Your fluid intake should be based on your urinary output.”
• Correct Answer: B) “Your fluid intake should be limited to 1,000 to 1,500 mL per day.”

137. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which of the following observations by the nurse indicates the client may need suctioning?

• A) The client has a nonproductive cough
• B) The client is talking in short sentences
• C) The client has a respiratory rate of 24 breaths per minute
• D) The client has coarse crackles in the lungs
• Correct Answer: D) The client has coarse crackles in the lungs

138. The nurse is caring for a client who is postoperative following a total hip arthroplasty. The nurse should place a wedge-shaped pillow between the client’s legs for which of the following purposes?

• A) Prevent pressure ulcers on the heels
• B) Maintain abduction of the hips
• C) Decrease external rotation of the hips
• D) Prevent adduction of the hips
• Correct Answer: D) Prevent adduction of the hips

139. The nurse is assessing a newborn. Which of the following findings should be reported to the health care provider immediately?

• A) Heart rate of 136 beats per minute
• B) Respiratory rate of 60 breaths per minute
• C) Yellowish tint to the skin
• D) Head circumference of 33 cm
• Correct Answer: C) Yellowish tint to the skin

140. The nurse is providing teaching to a client who has been prescribed a low-sodium diet. Which of the following statements by the client indicates a need for further teaching?

• A) “I will avoid canned vegetables.”
• B) “I will avoid processed meats.”
• C) “I will avoid fresh fruits and vegetables.”
• D) “I will avoid adding salt to my food.”
• Correct Answer: C) “I will avoid fresh fruits and vegetables.”

141. The nurse is caring for a client with diabetes mellitus who is experiencing hypoglycemia. Which of the following symptoms should the nurse expect to find?

• A) Polyuria
• B) Diaphoresis
• C) Bradycardia
• D) Flushed skin
• Correct Answer: B) Diaphoresis

142. The nurse is teaching a client with a new diagnosis of type 1 diabetes mellitus about insulin therapy. Which of the following information should the nurse include?

• A) Insulin should be stored in the freezer
• B) Rotate injection sites to prevent lipodystrophy
• C) Always inject insulin into the same site
• D) Mix long-acting insulin with short-acting insulin
• Correct Answer: B) Rotate injection sites to prevent lipodystrophy

143. The nurse is caring for a client who is postoperative following a cholecystectomy. Which of the following actions should the nurse take to prevent respiratory complications?

• A) Encourage deep breathing and coughing every hour
• B) Administer an expectorant every 4 hours
• C) Place the client in a supine position
• D) Restrict the client to bedrest for 24 hours

144. The nurse is providing care for a client who is receiving enteral feedings via a nasogastric tube. Which of the following actions should the nurse take to prevent aspiration?

• A) Position the client on the left side during feeding
• B) Administer feedings at a slow, continuous rate
• C) Check for residual volume every 8 hours
• D) Flush the tube with 50 mL of water before feeding
• Correct Answer: B) Administer feedings at a slow, continuous rate

145. The nurse is assessing a client who is experiencing chest pain. Which of the following findings should the nurse identify as a manifestation of an acute myocardial infarction (MI)?

• A) Pain is relieved by nitroglycerin
• B) Pain radiates to the left arm
• C) Pain lasts less than 15 minutes
• D) Pain is reproducible with palpation
• Correct Answer: B) Pain radiates to the left arm

146. A client with chronic renal failure is receiving epoetin alfa (Epogen). Which of the following laboratory values should the nurse monitor to determine the effectiveness of the medication?

• A) Hemoglobin
• B) Serum creatinine
• C) Blood urea nitrogen
• D) Serum potassium
• Correct Answer: A) Hemoglobin

147. The nurse is caring for a client with a chest tube. Which of the following observations indicates that the chest tube is functioning correctly?

• A) Continuous bubbling in the water seal chamber
• B) Absence of tidaling in the water seal chamber
• C) Fluctuations in the water seal chamber with respirations
• D) Continuous bubbling in the suction control chamber
• Correct Answer: C) Fluctuations in the water seal chamber with respirations

148. The nurse is assessing a 2-year-old client with a possible diagnosis of congenital heart disease. Which of these is most likely to be seen with this diagnosis?

• A) Several otitis media episodes in the last year
• B) Weight and height in the 10th percentile since birth
• C) Takes frequent rest periods while playing
• D) Changing food preferences and dislikes
• Correct Answer: C) Takes frequent rest periods while playing

149. The nurse is caring for a 10-year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is

• A) Urinary output of 30 ml per hour
• B) No complaints of thirst
• C) Increased hematocrit
• D) Good skin turgor around burn
• Correct Answer: A) Urinary output of 30 ml per hour

150. The nurse is caring for a client who is experiencing severe pain due to metastatic cancer. Which of the following interventions is most appropriate for the nurse to implement?

• A) Administer pain medication around the clock
• B) Administer pain medication only when the client requests it
• C) Administer pain medication before physical activity
• D) Administer pain medication with meals
• Correct Answer: A) Administer pain medication around the clock

151. The nurse is teaching a client with hypertension about lifestyle changes. Which of the following recommendations should the nurse include in the teaching?

• A) Increase sodium intake
• B) Limit alcohol consumption
• C) Reduce physical activity
• D) Avoid potassium-rich foods
• Correct Answer: B) Limit alcohol consumption

152. The nurse is assessing a client who is at 28 weeks of gestation. Which of the following findings should the nurse report to the provider?

• A) Fetal heart rate of 150 beats per minute
• B) Fundal height of 30 cm
• C) Weight gain of 0.5 kg in 1 week
• D) Blood pressure of 140/90 mm Hg
• Correct Answer: D) Blood pressure of 140/90 mm Hg

153. The nurse is providing teaching to a client who is scheduled for a colonoscopy. Which of the following statements by the client indicates an understanding of the teaching?

• A) “I will need to follow a clear liquid diet for 24 hours before the procedure.”
• B) “I can drink milk up to 12 hours before the procedure.”
• C) “I should take my regular medications with a full glass of water on the day of the procedure.”
• D) “I will need to have a full bladder for the procedure.”
• Correct Answer: A) “I will need to follow a clear liquid diet for 24 hours before the procedure.”

154. The nurse is caring for a client who has a new prescription for warfarin (Coumadin). Which of the following laboratory tests should the nurse monitor to determine the effectiveness of the medication?

• A) Complete blood count (CBC)
• B) Prothrombin time (PT) and international normalized ratio (INR)
• C) Activated partial thromboplastin time (aPTT)
• D) Platelet count
• Correct Answer: B) Prothrombin time (PT) and international normalized ratio (INR)

155. The nurse is caring for a client with acute pancreatitis. Which of the following interventions should the nurse include in the plan of care?

• A) Encourage small, frequent meals
• B) Administer antacids as prescribed
• C) Maintain the client on bed rest
• D) Place the client in a supine position
• Correct Answer: C) Maintain the client on bed rest

156. The nurse is teaching a client who has a new prescription for levothyroxine (Synthroid). Which of the following information should the nurse include in the teaching?

• A) Take the medication with food
• B) Take the medication at bedtime
• C) Take the medication on an empty stomach
• D) Take the medication with a full glass of milk
• Correct Answer: C) Take the medication on an empty stomach

157. The nurse is assessing a client who has been taking furosemide (Lasix). Which of the following findings indicates that the client is experiencing an adverse effect of the medication?

• A) Bradycardia
• B) Hypernatremia
• C) Hypokalemia
• D) Hypercalcemia
• Correct Answer: C) Hypokalemia

158. The nurse is assessing a client with end-stage renal disease. Which of the following findings should the nurse identify as a manifestation of uremia?

• A) Pruritus
• B) Polyuria
• C) Hypotension
• D) Bradycardia
• Correct Answer: A) Pruritus

159. The nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following findings indicates that the bladder irrigation is effective?

• A) The client reports decreased bladder spasms
• B) The client’s urine is light pink
• C) The client’s catheter is draining freely
• D) The client has a reduced urge to void
• Correct Answer: B) The client’s urine is light pink

160. The nurse is assessing a 2-year-old child who is brought to the emergency department with dehydration. Which of the following findings should the nurse expect?

• A) Bulging fontanels
• B) Bradycardia
• C) Increased urine output
• D) Dry mucous membranes
• Correct Answer: D) Dry mucous membranes

161. The nurse is providing care to a client with a chest tube. Which of the following actions should the nurse take to ensure the chest tube is functioning correctly?

• A) Clamp the chest tube intermittently
• B) Milk the chest tube every 2 hours
• C) Keep the drainage system below chest level
• D) Secure the chest tube to the bed linens
• Correct Answer: C) Keep the drainage system below chest level

162. The nurse is teaching a client who is scheduled for a cardiac catheterization. Which of the following statements by the client indicates an understanding of the teaching?

• A) “I will be asleep during the procedure.”
• B) “I will need to lie flat for several hours after the procedure.”
• C) “I will need to restrict my fluid intake after the procedure.”
• D) “I will need to take a laxative the night before the procedure.”
• Correct Answer: B) “I will need to lie flat for several hours after the procedure.”

163. The nurse is providing care for a client who has had a stroke. Which of the following interventions should the nurse implement to prevent aspiration?

• A) Provide thin liquids
• B) Place the client in a supine position during meals
• C) Instruct the client to tilt the head back when swallowing
• D) Instruct the client to tuck the chin when swallowing
• Correct Answer: D) Instruct the client to tuck the chin when swallowing

164. The nurse is caring for a client who has a new prescription for digoxin (Lanoxin). Which of the following findings indicates that the medication is effective?

• A) Decreased heart rate
• B) Increased blood pressure
• C) Decreased respiratory rate
• D) Increased urine output
• Correct Answer: D) Increased urine output

165. The nurse is assessing a client who is 24 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A) Serosanguineous drainage on the surgical dressing
• B) Absent bowel sounds
• C) Oral temperature of 37.8°C (100°F)
• D) Urine output of 20 mL/hr
• Correct Answer: D) Urine output of 20 mL/hr

166. The nurse is providing teaching to a client who is scheduled for a total hip arthroplasty. Which of the following information should the nurse include in the teaching?

• A) Avoid bending at the waist beyond 90 degrees
• B) Avoid crossing the legs at the ankles
• C) Sit in a low chair
• D) Lie on the affected side
• Correct Answer: A) Avoid bending at the waist beyond 90 degrees

167. The nurse is caring for a client with a history of angina. Which of the following statements by the client indicates a need for further teaching?

• A) “I should call 911 if my chest pain is not relieved by nitroglycerin.”
• B) “I should take nitroglycerin before physical exertion.”
• C) “I should stop taking nitroglycerin if I experience a headache.”
• D) “I should store nitroglycerin tablets in a dark, dry place.”
• Correct Answer: C) “I should stop taking nitroglycerin if I experience a headache.”

168. The nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings indicates that the chest tube is functioning correctly?

• A) Absence of breath sounds on the affected side
• B) Continuous bubbling in the water seal chamber
• C) Fluctuations in the water seal chamber with respirations
• D) Intermittent bubbling in the suction control chamber
• Correct Answer: C) Fluctuations in the water seal chamber with respirations

169. The nurse is providing teaching to a client who has a new prescription for warfarin (Coumadin). Which of the following information should the nurse include in the teaching?

• A) Avoid foods high in vitamin K
• B) Take the medication on an empty stomach
• C) Use an electric razor when shaving
• D) Increase intake of green, leafy vegetables
• Correct Answer: A) Avoid foods high in vitamin K

170. The nurse is caring for a client who is 2 hours postoperative following a laminectomy. Which of the following findings should the nurse report to the provider immediately?

• A) Urinary retention
• B) Mild incisional pain
• C) Clear drainage on the surgical dressing
• D) Paresthesia in the lower extremities
• Correct Answer: D) Paresthesia in the lower extremities