CA PRELIMS 1. A patient with coarse crackles at the base of both lungs suddenly becomes agitated, anxious, cyanotic, and dyspneic. Which of the following positions is appropriate? a. High Fowler’s b. Left Sim’s c. Modified Trendelenburg d. Supine Answer: a. Appropriate position for pulmonary edema is high fowlers with legs dangling to decrease venous return to the heart 2. A nurse on a medical-surgical unit receives a report on multiple patients. Based on this report, which patient should the nurse assess first? a. A patient who underwent a colon resection 3 hours ago and is bleeding b. A patient who was rescued from a burning building and shows evidence of smoke inhalation c. A patient with gastroenteritis who is throwing up large amounts of vomit d. A patient with peritonitis who has pain level of “8” on a scale from 1 to 10 Answer: c. Assess patient who shows evidence of smoke inhalation (ABC) 3. The nurse provides instruction to a community group about lung cancer prevention, health promotion, and smoking cessation. Which statement made by a member of the group indicates the need for further instruction? a. “Even though I am getting nicotine in my patches, I am not being exposed to all of the other toxic stuff in cigarettes.” b. “I can’t get lung cancer because I don’t smoke.” c. “My husband needs to take smoking cessation classes.” d. “We installed a radon detector in our home.” Answer: b. Smoking is not the only cause of lung cancer 4. A patient with type 2 diabetes, coronary artery disease, and peripheral arterial disease developed hospital-acquired pneumonia (HAP) and has been receiving intravenous (IV) antibiotics for 4 days. Which parameter monitored by the nurse best indicates the effectiveness of treatment? a. Color of sputum b. Lung sounds c. Saturation level d. White blood cell count Answer: d. 5. The nurse is caring for a patient who has been receiving mechanical ventilation (MV) for 4 days. During multidisciplinary morning rounds, the physician question the development of a ventilator-assisted pneumonia (VAP). Which of the following manifestations does the nurse assess as the best indicator of VAP? a. b. c. d. Blood-tinged sputum Positive blood cultures Positive, purulent sputum Rhonchi and crackles Answer: c. 2-3 days after patient is on mechanical ventilator, monitor patient for VAP 6. A nursing diagnosis of “ineffective airway clearance related to pain” is identified for a patient with open abdominal surgery 2 days ago. Which intervention should the nurse implement first? a. Administer prescribed analgesic medication for incisional pain b. Encourage use of incentive spirometer every 2 hours while awake c. Offer an additional pillow to splint the incision while coughing d. Promote increased oral fluid intake Answer: a. 7. A student nurse initiates oxygen with a nonrebreather mask for a patient with acute respiratory distress. While reassessing the patient, the RN notices the reservoir bag is fully deflating on inspiration. What immediate action does the RN take to correct the problem? a. Elevates the head of the bed b. Increases the oxygen flow c. Opens both flutter valves (ports) on the mask d. Tightens the face mask straps Answer: b. 8. The nurse develops a care plan for a critically ill patient with acute respiratory distress syndrome (ARDS) who is on a mechanical ventilator. What is the priority nursing diagnosis (ND)? a. Imbalanced nutrition b. Impaired gas exchange c. Impaired tissue integrity d. Risk for infection Answer: b. 9. A nurse is reviewing the laboratory results of a patient admitted for an asthma exacerbation. Elevation of which of these cells indicates that the patient’s asthma may have been triggered by an allergic reaction? a. Eosinophils b. Lymphocytes c. Neutrophils d. Reticulocytes Answer: a. Eosinophil count will increase when there is an allergic reaction 10. An obese 85-year-old client, who is an avid gardener and eats only home-grown fruits, legumes, and vegetables, is admitted to the hospital with pneumonia after having an upper respiratory tract infection for a week. Which factor puts the patient at greatest risk for developing pneumonia? a. Advanced age b. Environmental exposure c. Nutritional deficit d. Obesity Answer: a. 11. The nurse conducts a program about strategies to prevent community-acquired pneumonia at a center for senior citizens. Which statement made by a participant indicates the need for further instruction? a. “I got flu vaccine and it can help to prevent pneumonia.” b. “I got the one-time pneumonia shot, so I won’t need it again.” c. “I stopped smoking a year ago, so that should help me a lot.” Answer: b. 12. A patient is experiencing an asthma attack. The nurse assesses extreme anxiety, dyspnea, nonproductive cough, inspiratory and expiratory wheezing, and diminished breath sounds. Respiration are 36/min, pulse is 122/min, and pulse oximeter shows 87% on room air. Which is the priority nursing diagnosis (ND) for this patient? a. Anxiety related to hypoxia and fear of suffocation b. Impaired gas exchange related to alveolar hypoventilation c. Ineffective airway clearance related to abnormal viscosity of mucus d. Ineffective breathing pattern related to decreased lung expansion Answer: b. No immediate risk for airway compromise; anxiety=not appropriate 13. The nurse is caring for an intubated patient who oxygen saturation begins to drop. What action should the nurse take first? a. Auscultate lung sounds bilaterally b. Hyper-oxygenate with 100% oxygen c. Manually ventilate with bag valve mask d. Suction the endotracheal tube Answer: a. Auscultating the lung sounds is the quickest intervention the nurse can do. Hyperoxygenation will not work when the tube is dislocated. 14. A patient with left lobar pneumonia is transferred to the intensive care unit due to increasing respiratory distress. While providing care for the patient, the nurse notes a significant drop in saturation when the patient is placed in which position? a. High Fowler’s b. Left side c. Right side d. Semi-Fowler’s Answer: b. Place patient on the right side because of gravity mismatch. Positioning the patient on the left side will decrease oxygen saturation. 15. The charge nurse of the emergency department (ED) is mentoring a new registered nurse (RN). They are caring for a patient who has a chest tube connected to wall suction for a pneumothorax. The patient is being transferred from the ED to the telemetry unit. Which action by the new RN would cause the charge nurse to intervene? a. Clamping the chest tube at the insertion site during the transfer b. Disconnecting the suction tubing from the wall suction unit c. Hanging the chest tube connection unit to the underside of the stretcher d. Taping connections between the chest tube and suction tubing Answer: a. Clamping can cause the air to accumulate in the pleural cavity. This can also develop to tension pneumothorax. 16. An elderly patient is brought to the emergency department with lethargy, chills, and sharp colicky pain with deep breathing. Pulse oximeter shows 93% on room air and respirations are 24/min. What is the nurse’s initial action? a. Administer intravenous (IV) morphine b. Auscultate the client’s lung sounds c. Initiate an IV infusion of normal saline d. Initiate nasal oxygen at 3 L/min Answer: b. 17. The nurse is assisting the attending physician with a client’s chest tube removal. Just as the physician prepares to pull the chest tube, what instructions should the nurse give the patient? a. “Breathe as you normally would.” b. “Inhale and exhale slowly.” c. “Take a breath in, hold it, and bear down.” d. “Take rapid shallow breaths, similar to panting.” Answer: c. To prevent tension pneumothorax 18. The nurse in the outpatient procedure unit is caring for a patient immediately post bronchoscopy. Which assessment data indicate that the nurse needs to contact the physician immediately? a. Absence of gag reflex b. Bright red blood mixed with sputum c. Headache d. Respirations 10/min and saturation of 92% Answer: b. Bright red blood mixed with sputum indicates hemorrhage. Absence of gag reflex for 2 hours is present due to administration of anesthesia. 19. A patient is brought to the emergency department following a motor vehicle collision. The client’s admission vital signs are blood pressure 70/50 mmHg, pulse 123/min, and respirations 8/min. The nurse anticipates the results of which diagnostic test to best evaluate the patient’s oxygenation and ventilation status? a. Arterial blood gas b. Chest x-ray c. Hematocrit and hemoglobin d. Serum lactate level Answer: a. 20. The nurse cares for a patient who returns from the operating room after a tracheostomy tube placement procedure. Which of the following is the nurse’s priority when caring for a patient with a new tracheostomy? a. Checking the inner cannula within the first 8 hours to help prevent mucus plugs b. Checking the tightness of ties and adjusting if necessary, allowing 1 finger to fit under the tie c. Deflating and re-inflating the cuff every 4 hours to prevent mucosal tissue damage d. Performing frequent mouth care every 2 hours to help prevent infection Answer: b. 21. The nurse is counseling an overweight young man on entry into a weight reduction program. The nurse is aware that the client is most likely to begin and maintain the program if he a. Is aware of being overweight b. Has read about the program c. Feels competent about making the change d. Can envision himself as thinner Answer: c. 22. The nursing intervention that is least likely to motivate clients to change health behavior is a. Encouraging clients to see problems as solvable b. Inspiring clients to believe in themselves and their ability to cope c. Providing clients positive feedback when they show interest in change d. Convincing clients to accept solutions that are unattractive to them Answer: d. 23. The school nurse reviewing records of 300 high school students notes that 29 are “seriously” overweight. The nurse interprets this to mean that these students are a. 100 pounds overweight b. Physically impaired by their excess weight c. No more than 50 pounds overweight d. Already exhibiting clinical manifestations of hypertension and diabetes Answer: a. 24. In directing clients to seek medical evaluation before starting a program of physical activity, the nurse could omit a client who has a. Hypertension b. Elevated serum cholesterol c. Quit smoking for 10 years d. Family history of cardiovascular disease Answer: c. 25. The nurse would recommend that in order for a client’s body to resist stress better, the client should reduce her intake of a. Oatmeal with raisins b. Prunes and apricots c. Green beans with almonds d. Pancakes with syrup Answer: d. 26. The nurse making a physical activity prescription for an overweight housewife will emphasize the activity should be done a. 15 minutes four times a day b. 30 minutes twice a day c. 60 minutes a day d. As frequently as possible Answer: c. 27. The nurse motivating an overweight housewife to increase her physical activity would include the strategy of a. Setting a high goal to stimulate the client to greater effort b. Having the client perform the activity without the distraction of others c. Insisting that the selected activity goal be met before taking up another activity d. Selecting an activity that is in the scope of the client’s daily chores Answer: d. 28. Prevent weakness of newly healed wound = intake of vitamin C 29. The history finding in a client with elevated carcinoembryonic antigen (CEA) that suggests to the nurse that this result might not be related to colorectal cancer is a a. High-fiber diet b. History of heavy smoking c. Regular exercise program d. Sedentary lifestyle Answer: b. 30. The nurse who is obtaining a stool specimen for ova and parasites should a. Use a sterile collection container b. Collect only one specimen c. Administer mineral oil before specimen collection d. Take the specimen to the laboratory immediately Answer: d. 31. 350 ml in a 24-hour period; 1500 ml oral intake=patient is oliguric 32. Glucosuria in urinalysis = serum glucose level is above renal threshold 33. To obtain a urine specimen for culture, the nurse would choose the a. Random method b. Double-voided method c. Midstream clean-catch method d. 24-hour collection Answer: c. 34. A client experiencing hematuria tells the nurse that the bleeding occurs at the end of urination, which could indicate a lesion in the a. Middle urinary tract b. Lower bladder c. Renal pelvis d. Bladder neck Answer: d. 35. The nurse explains that a large increase of urobilinogen in the client’s urine is consistent with the diagnosis of a. Hepatitis B b. Acquired immunodeficiency syndrome (AIDS) c. Gastroenteritis d. Cancer of the lung Answer: a. 36. The nurse explains that in the administration of total parenteral nutrition (TPN), an unsuitable site is the a. Vena cava b. Jugular vein c. Brachial vein d. Subclavian vein Answer: c. TPN site should be part of the central venous circulation 37. An older client has had a urinary tract infection for 5 weeks despite the use of several antibiotics. The home health nurse assesses that the prolonged period of infection is associated with a. Resistant organisms b. Poor nutritional state c. Tight underwear d. Inadequate hygiene Answer: b. 38. After discussing reasonable weight loss goals with a client who is 5 ½ feet tall and weighs 210 pounds, the nurse would see the need for further teaching with the client’s statement that a. I will try to eat very slowly b. I will limit my intake to 500 calories a day c. I’ll try to pick foods from all five of the basic food groups d. It’s important for me to begin a regular exercise program Answer: b. 39. When assisting a dysphagic client to eat, the nurse should a. Place the client in the semi-Fowler’s position b. Have the client slightly flex the neck for swallowing c. Place the client in the Sims position for 15 minutes after each meal d. Use the fingers to check the client’s mouth for food around dentures Answer: b. 40. The nurse is assessing a client who describes “stomach discomfort.” The most appropriate sequence for conducting the physical examination of the abdomen is a. Inspection, palpation, percussion, auscultation b. Auscultation, percussion, palpation, inspection c. Inspection, auscultation, percussion, palpation d. Palpation, percussion, auscultation, inspection Answer: c. 41. The nurse is evaluating whether nonprofessional staff understand how to prevent transmission of HIV. Which of the following behaviors indicates correct application of universal precautions? a. A lab technician rests his hand on the desk to steady it while recapping the needle after drawing the blood b. An aide wears gloves to feed a helpless client c. An assistant puts on a mask and protective eye wear before assisting the nurse to suction a tracheostomy d. A pregnant worker refuses to care for a client known to have AIDS Answer: c. 42. After myelogram, most important action in regard to safety = perform neurological assessment 43. Meniere’s disease consideration in regard to safety = ask nursing assistant to walk with patient 44. During report, the previous nurse emphasized that one of the newly admitted patients is on seizure precautions. The incoming nurse is correct when she performs which of the following actions to the client? a. Maintain the client’s bed in the lowest position b. Serve the client’s food in paper and plastic containers c. Move the client to a room closer to the nurse’s station d. Ensure that soft limb restraints are applied to upper extremities Answer: a. 45. A patient arrives in the ER with suspected appendicitis. Which of the following actions, if performed by the UAP (Unlicensed Assistive Personnel) caring for the patient, would require further teaching in regard to safety? a. The UAP gives the patient heat pack for comfort b. The UAP reminds the patient to stay in bed c. The UAP does not give the patient any fluids or food d. The UAP allows the patient to lay in whatever position is most comfortable Answer: a. 46. The medical/surgical nurse watches a student nurse prepare a sterile field. Which of the following actions, if performed by the student nurse, requires further instruction? a. The student nurse drops the sterile gloves into the sterile field before disposing of the outer packaging b. The student nurse places the sterile drape, then turns to grab a packaged set of sterile gloves from the table behind her c. The student nurse’s hands, once in the sterile gloves, do not go above her head or below her waist d. The student nurse places an unwrapped sterile 4x4 on the sterile drape Answer: b. 47. Which of the following is the first priority in preventing infections when providing care for a client? a. Handwashing b. Wearing gloves c. Using a barrier between client’s furniture and nurse’s bag d. Wearing gowns and goggles Answer: a. 48. The nurse in charge is evaluating the infection control procedures on the unit. Which finding indicates a break in technique and the need for education of staff? a. The nurse aide is not wearing gloves when feeding an elderly client b. A client with active tuberculosis is asked to wear a mask when he leaves his room to go to another department for testing c. A nurse with open, weeping lesions of the hands puts on gloves before giving direct client care d. The nurse puts on a mask, a gown, and gloves before entering the room of a client on strict isolation Answer: c. 49. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which of the following nursing measures should the nurse do first? a. Institute seizure precautions b. Assess neurologic status c. Place in respiratory isolation d. Assess vital signs Answer: c. 50. A 2-year-old is to be admitted in the pediatric unit. He is diagnosed with febrile seizures. In preparing for his admission, which of the following is the most important nursing action? a. Order a stat admission CBC b. Place a urine collection bag and specimen cup at the bedside c. Place a cooling mattress on his bed d. Pad the side rails of his bed Answer: d. 51. A nurse who was assigned in pedia ward made her nursing rounds. Among the patients assigned to her care, which of them should the nurse consider has the greatest risk for choking and suffocating? a. A toddler playing with his 9-year-old brother’s construction set b. A 4-year-old eating yogurt for lunch c. An infant covered with a small blanket and asleep in the crib d. A 3-year-old drinking a glass of juice Answer: a. 52. A nurse trainee in OR is unfamiliar with a new piece of OR equipment that is scheduled to be used today. What is the best course of action by the trainee? a. Ask another nurse for instruction on how to use it b. Wait until she has attended on class on using the equipment before using it c. Get another nurse who is familiar with the equipment to operate it d. Read the instructions provided with the equipment Answer: c. 53. Most at risk for nosocomial infection = indwelling catheter in place 54. The nurse is caring for clients on the pediatric unit. An 8-year-old client with 2nd and 3rd degree burns on the right thigh is being admitted. The nurse should assign the new client to which of the following roommates? a. A 2-year-old with chicken pox b. A 4-year-old with asthma c. A 9-year-old with acute diarrhea d. A 10-year-old with MRSA Answer: b. 55. A nurse has given a client instructions about crutch safety. The nurse evaluates that the client needs reinforcement of information if the client states a. The need to have spare crutches and tips available b. That crutch tips will not slip even when wet c. Not to use someone else’s crutches d. That crutch tips should be inspected periodically for wear Answer: b. 56. Dressing change infected surgical incision = clean gloves for removal then sterile gloves for application of new dressing 57. A physician ordered a sterile dressing tray set up in a client’s room to insert a subclavian central venous catheter. Which of the following steps is done first to set up the sterile field? a. Open the tray toward the nurse b. Use correct handwashing technique c. Put on sterile gloves before opening the tray d. Place the sterile dressing tray on an overbed table Answer: b. 58. A student nurse observes that the site of the client’s IV catheter is reddened, warm, painful and slightly edematous proximal to the insertion point. The student nurse takes appropriate steps to care for the client and understands that the client experienced which condition? a. Phlebitis of the vein b. Infiltration of the IV line c. Hypersensitivity to the IV solution d. Allergic reaction to the IV catheter material Answer: a. 59. The nurse assesses a client’s surgical incision for signs of infection. Which finding of the nurse would be interpreted as a normal finding at the post-operative site? a. Red, hard skin b. Serous drainages c. Purulent drainage d. Warm, tender skin Answer: b. 60. A 2-year-old begins to scream, kick and wave his arms angrily when the nurse lowers his siderails to take his temperature and other vital signs. The child and nurse are alone in the room. What is the best action for the nurse to take? a. Leave the child alone until his mother comes to visit and can be there to help hold him on her lap for the procedures b. Immediately call another nurse to come and help hold the client still for the procedures c. Hold the child and talk calmly while showing him something of interest and explain what is going to be done d. Tell the child he will be left alone for 2 minutes without his toys and he must quiet down during that time Answer: c.
