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HESI Med Surg Exit Exam V1 -with 100% verified
solutions-2023-2024
swift river (University of North Texas Health Science Center)
Studocu is not sponsored or endorsed by any college or university
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HESI Med Surg Exit Exam V1 -with latest solutions2023-2024
TEST 1
Multiple Choice
Identify the letter of the choice that best completes the statement or answers the question.
1. While assessing a client with diabetes mellitus, the nurse observes an absence of hair growth
on the client's legs. What additional assessment provides further data to support this
finding?
a. Palpate for the presence of femoral pulses bilaterally.
b. Assess for the presence of a positive Homan's sign.
c. Observe the appearance of the skin on the client's legs.
d. Watch the client's posture and balance during ambulation.
2. The healthcare provider prescribes 15 mg/kg of Streptomycin for an infant weighing 4 pounds.
The drug is diluted in 25 ml of D5W to run over 8 hours. How much Streptomycin will the
infant receive?
a. 9 mg.
b. 18 mg.
c. 27 mg.
d. 36 mg.
3. In assessing a client with preeclampsia who is receiving magnesium sulfate, the nurse
determines that her deep tendon reflexes are 1+; respiratory rate is 12 breaths/minute;
urinary output is 90 ml in 4 hours; magnesium sulfate level is 9 mg/dl. Based on these
findings, what intervention should the nurse implement?
a. Continue the magnesium sulfate infusion as prescribed.
b. Decrease the magnesium sulfate infusion by one-half.
c. Stop the magnesium sulfate infusion immediately.
d. Administer calcium gluconate immediately.
4. A client is on a mechanical ventilator. Which client response indicates that the neuromuscular
blocker tubocurarine chloride (Tubarine) is effective?
a. The client’s expremities are paralyzed.
b. The peripheral nerve stimulator causes twitching.
c. The client clinches fist upon command.
d. The client’s Glagow Coma Scale score is 14.
5. An elderly female client comes to the clinic for a regular check-up. The client tells the nurse
that she has increased her daily doses of acetaminophen (Tylenol) for the past month to
control joint pain. Based on this client's comment, what previous lab values should the nurse
compare with today's lab report?
a. Look at last quarter's hemoglobin and hematocrit, expecting an increase today due
to dehydration.
b. Look for an increase in today's LDH compared to the previous one to assess
for possible liver damage.
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c. Expect to find an increase in today's APTT as compared to last quarter's due
to bleeding.
d. Determine if there is a decrease in serum potassium due to renal compromise.
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Name:
ID: A
6. Aspirin is prescribed for a 9-year-old child with rheumatic fever to control the inflammatory
process, promote comfort, and reduce fever. What intervention is most important for the
nurse to implement?
a. Instruct the parents to hold the aspirin until the child has first had a tepid sponge
bath.
b. Administer the aspirin with at least two ounces of water or juice.
c. Notify the healthcare provider if the child complains of ringing in the ears.
d. Advise the parents to question the child about seeing yellow halos around objects.
7. Which signs or symptoms are characteristic of an adult client diagnosed with Cushing's
syndrome?
a. Husky voice and complaints of hoarseness.
b. Warm, soft, moist, salmon-colored skin.
c. Visible swelling of the neck, with no pain.
d. Central-type obesity, with thin extremities.
8. A charge nurse agrees to cover another nurse’s assignment during a lunch break. Based on the
status report provided by the nurse who is leaving for lunch, which client should be checked
first by the charge nurse? The client
a. admitted yesterday with diabetec ketoacidosis whose blood glucose level
is now 195 mg/dl.
b. with an ileal conduit created two days ago with a scant amount of blood in
the drainage pouch.
c. post-triple coronary bypass four days ago who has serosanguinous drainage
in the chest tube.
d. with a pneumothorax secondary to a gunshot wound with a current pulse
oximeter reading of 90%.
9. An outcome for treatment of peripheral vascular disease is, "The client will have decreased
venous congestion." What client behavior would indicate to the nurse that this outcome has
been met?
a. Avoids prolonged sitting or standing.
b. Avoids trauma and irritation to skin.
c. Wears protective shoes.
d. Quits smoking.
10. The healthcare provider performs a paracentesis on a client with ascites and 3 liters of fluid
are removed. Which assessment parameter is most critical for the nurse to monitor following
the procedure?
a. Pedal pulses.
b. Breath sounds.
c. Gag reflex.
d. Vital signs.
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11. The nurse is administering sevelamer (RenaGel) during lunch to a client with end stage renal
disease (ESRD). The client asks the nurse to bring the medication later. The nurse should
describe which action of RenaGel as an explanation for taking it with meals?
a. Prevents indigestion associated with ingestion of spicy foods.
b. Binds with phosphorus in foods and prevents absorption.
c. Promotes stomach emptying and prevents gastric reflux.
d. Buffers hydrochloric acid and prevents gastric erosion.
12. The nurse formulates a nursing diagnosis of, "High risk for ineffective airway clearance" for
a client with myasthenia gravis. What is the most likely etiology for this nursing diagnosis?
a. Pain when coughing.
b. Diminished cough effort.
c. Thick dry secretions.
d. Excessive inflammation.
13. Following a CVA, the nurse assess that a client developed dysphagia, hypoactive bowel sounds
and firm, distended abdomen. Which prescription for the client should the nurse question?
a. Continous tube feeding at 65 ml/hr via gastrostomy.
b. Total parenteral nutrition to be infused at 125 ml/hour.
c. Nasogastric tube connected to low intermittent suction.
d. Metoclopramide (Reglan) intermittent piggyback.
14. A client's telemetry monitor indicates the sudden onset of ventricular fibrillation. Which
assessment finding should the nurse anticipate?
a. Bounding erratic pulse.
b. Regularly irregular pulse.
c. Thready irregular pulse.
d. No palpable pulse.
15. In assessing a 70-year-old female client with Alzheimer's disease, the nurse notes that she has
deep inflamed cracks at the corners of her mouth. What intervention should the nurse include
in this client's plan of care?
a. Scrub the lesions with warm soapy water.
b. Encourage the client to drink orange juice for added vitamin C.
c. Notify the healthcare provider of the need for oral antibiotics.
d. Ensure that the client gets adequate B vitamins in foods or supplements.
16. A young adult female client is seen in the emergency department for a minor injury following
a motor vehicle collision. She states she is very angry at the person who hit her car. What is
the best nursing response?
a. "You are lucky to be alive. Be grateful no one was killed."
b. "I understand your car was not seriously damaged."
c. "You are upset that this incident has brought you here."
d. "Have you ever been in the emergency department before?"
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17. An 85-year-old male resident of an extended care facility reaches for the hand of the
unlicensed assistive personnel (UAP) and tries to kiss her hand several times during his
morning care. The UAP reports the incident to the charge nurse. What is the best assessment
of the situation?
a. This is sexual harassment and needs to be reported to the
administration immediately.
b. The UAP needs to be reassigned to another group of residents, preferably females
only.
c. The client may be suffering from touch deprivation and needs to know
appropriate ways to express his need.
d. The resident needs to know the rules concerning unwanted touching of the staff
and the consequences.
18. The parents of a newborn infant with hypospadias are concerned about when the surgical
correction should occur. What information should the nurse provide?
a. Repair should be done by one month to prevent bladder infections.
b. Repairs typically should be done before the child is potty-trained.
c. Delaying the repair until school age reduces castration fears.
d. To form a proper urethra repair, it should be done after sexual maturity.
19. In evaluating teaching of a client about wearing a Holter monitor, which statement made by
the client would indicate to the nurse that the client understands the procedure?
a. “I must record any symptoms occurring with my activity.”
b. “I am not looking forward to staying in bed for 24 hours.”
c. “I really am dreading the frequent blood drawing.”
d. “I know that I shouldn’t get close to my microwave oven.”
20. A 9-year-old female client was recently diagnosed with diabetes mellitus. Which symptom will
her parents most likely report?
a. Refuses to eat her favorite meals at home.
b. Drinks more soft drinks than previously.
c. Voids only one or two times per day.
d. Gained 10 pounds within one month.
21. The nurse is caring for four clients: Client A, who has emphysema and whose oxygen
saturation is 94%; Client B, with a postoperative hemoglobin of 8.7 mg/dl; Client C, newly
admitted with a potassium level of 3.8 mEq/L; and Client D, scheduled for an
appendectomy who has a white blood cell count of 15,000 mm3. What intervention should
the nurse implement?
a. Increase Client A's oxygen to 4 liters per minute via nasal cannula.
b. Determine if Client B has two units of packed cells available in the blood bank.
c. Ask the dietician to add a banana to Client C's breakfast tray.
d. Inform Client D that surgery is likely to be delayed until the infection is treated.
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22. A recently widowed middle-aged female client presents to the psychiatric clinic for evaluation
and tells the nurse that she has "little reason to live." She describes one previous suicidal
gesture and admits to having a gun in her home. To maintain the client's confidentiality and
to help ensure her safety, which action is best for the nurse to implement?
a. Encourage the client to remove the gun from her possession.
b. Notify the client's healthcare provider of the availability of the weapon.
c. Contact a person of the client's choosing to remove the weapon from the home.
d. Call the local police department and have the weapon removed from the home.
23. It is most important for the registered nurse (RN) who is working on a medical unit to provide
direct supervision in which situation?
a. A graduate nurse needs to access a client's implanted port to start an infusion of
Ringer's Lactate.
b. A postpartum nurse pulled to the unit needs to start a transfusion of packed
red blood cells.
c. A practical nurse is preparing to assist the healthcare provider with a lumbar
puncture at the bedside.
d. An unlicensed assistive personnel is preparing to weigh an obese bedfast
client using a bed scale.
24. A nurse is completing the health history for a 25-year-old male client who reports that he is
allergic to penicillin. Which question should the nurse ask after receiving this
information?
a. "Are you allergic to any other medications?"
b. "How often have you taken penicillin in the past?"
c. "Is anyone else in your family allergic to penicillin?"
d. "What happens to you when you take penicillin?"
25. A 10-year-old child with meningitis is suspected of having diabetes insipidus. In evaluating the
child's laboratory values, which finding is indicative of diabetes insipidus?
a. Decreased urine specific gravity.
b. Elevated urine glucose.
c. Decreased serum potassium.
d. Increased serum sodium.
26. A client with myelogenous leukemia is receiving an autologous bone marrow transplantation
(BMT). What is the priority intervention that the nurse should implement when the bone
marrow is repopulating?
a. Administer sargramostim (Leukine, Prokine).
b. Infuse PRBC and platelet transfusions.
c. Give parental prophylactic antibiotics.
d. Maintain a protective isolation environment.
27. A 38-year-old male client collapsed at his outside construction job in Texas in July. His
admitting vital signs to ICU are, BP 82/70, heart rate 140 beats/minute, urine output 10 ml/hr,
skin cool to the touch. Pulmonary artery (PA) pressures are, PAWP 1, PAP 8/2, RAP -1, SVR
1600. What nursing action has the highest priority?
a. Apply a hypothermia unit to stabilize core temperature.
b. Increase the client's IV fluid rate to 200 ml/hr.
c. Call the hospital chaplain to counsel the family.
d. Draw blood cultures x 3 to detect infection.
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28. A client who has Type 1 diabetes and is at 10-weeks gestation comes to the prenatal clinic
complaining of a headache, nausea, sweating, feeling shaky, and being tired all the time. What
action should the nurse take first?
a. Check the blood glucose level.
b. Draw blood for a Hemoglobin A1C.
c. Assess urine for ketone levels.
d. Provide the client with a protein snack.
29. A client in labor states, "I think my water just broke!" The nurse notes that the umbilical
cord is on the perineum. What action should the nurse perform first?
a. Administer oxygen via face mask.
c. Notify the operating room team.
b. Place the client in Trendelenburg.
c. Administer a fluid bolus of 500 ml.
30. The nurse is planning care for a non-potty-trained child with nephrotic syndrome. Which
intervention provides the best means of determining fluid retention?
a. Weigh the child daily.
b. Observe the lower extremities for pitting edema.
c. Measure the child's abdominal girth weekly.
d. Weigh the child's wet diapers.
31. The mother of a 9-month-old who was diagnosed with respiratory syncytial virus (RSV)
yesterday calls the clinic to inquire if it will be all right to take her infant to the first birthday
party of a friend's child the following day. What response should the nurse provide this
mother?
a. The child can be around other children but should wear a mask at all times.
b. The child will no longer be contagious, no need to take any further precautions.
c. Make sure there are no children under the age of 6 months around the
infected child.
d. Do not expose other children. RSV is very contagious even without direct oral
contact.
32. A client from a nursing home is admitted with urinary sepsis and has a single-lumen,
peripherally-inserted central catheter (PICC). Four medications are prescribed for 9:00 a.m.
and the nurse is running behind schedule. Which medication should the nurse administer
first?
a. Piperacillin/tazobactam (Zosyn) in 100 ml D5W, IV over 30 minutes q8 hours.
b. Vancomycin (Vancocin) 1 gm in 250 ml D5W, IV over 90 minutes q12 hours.
c. Pantoprazole (Protonix) 40 mg PO daily
d. Enoxaparin (Lovenox) 40 mg subq q24 hours.
33. Which action should the nurse implement to reduce the risk of vesicant extravasation in the
client who is receiving intravenous chemotherapy?
a. Administer an antiemetic before starting the chemotherapy.
b. Instruct the client to drink plenty of fluids during the treatment.
c. Keep the head of the bed elevated until the treatment is completed.
d. Monitor the client's intravenous site hourly during the treatment.
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34. An elderly male client reports to the clinic nurse that he is experiencing increasing nocturia
with difficulty initiating his urine stream. He reports a weak urine flow and frequent
dribbling after voiding. Which nursing action should be implemented?
a. Obtain a urine specimen for culture and sensitivity.
b. Encourage the client to schedule a digital rectal exam.
c. Advise the client to maintain a voiding diary for one week.
d. Instruct the client in effective techniques to cleanse the glans penis.
35. The nurse is performing an admission physical assessment of a newborn who is small for
gestational age (SGA). Which finding should the nurse report immediately to the
pediatric healthcare provider?
a. Heel stick glucose of 65 mg/dl.
b. Head circumference of 35 cm (14 inches).
c. Widened, tense, bulging fontanel.
d. High-pitched shrill cry.
36. Which client's laboratory value requires immediate intervention by a nurse?
a. A client with GI bleeding who is receiving a blood transfusion and has a
hemoglobin of 7 grams.
b. A client with pancreatitis who has a fasting glucose of 190 mg/dl today and
had 160 mg/dl yesterday.
c. A client with hepatitis who is jaundiced and has a bilirubin level that is 4 times
the normal value.
d. A client with cancer who has an absolute count of neutrophils < 500 today
and had 2,000 yesterday.
37. In planning the turning schedule for a bedfast client, it is most important for the nurse
to consider what assessment finding?
a. 4+ pitting edema of both lower extremities.
b. A Braden risk assessment scale rating score of ten.
c. Warm, dry skin with a fever of 100° F.
d. Hypoactive bowel sounds with infrequent bowel movements.
38. The healthcare provider prescribes naproxen (Naprosyn) 500 mg PO twice a day for a client
with osteoarthritis. During a follow-up visit one month later, the client tells the nurse, "The
pills don't seem to be working. They are not helping the pain at all." Which factor should
influence the nurse's response?
a. Noncompliance is probably affecting optimum medication effectiveness.
b. Drug dosage is inadequate and needs to be increased to four times a day.
c. The drug needs 4 to 6 weeks to reach therapeutic levels in the bloodstream.
d. NSAID response is variable and another NSAID may be more effective.
39. A nurse is interested in studying the incidence of infant death in a particular city and wants to
compare that city's rate to the state's rate. What state resource is most likely to provide this
information?
a. Disease registry.
b. Department of Health.
c. Bureau of Vital Statistics.
d. Census data.
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40. A 60-year-old male client is admitted to the hospital with the complaint of right knee pain for
the past week. His right knee and calf are warm and edematous. He has a history of diabetes
and arthritis. Which neurological assessment action should the nurse perform for this client?
a. Glasgow coma scale.
b. Pulses, paresthesia, paralysis distal to the right knee.
c. Pulses, paresthesia, paralysis proximal to the right knee.
d. Optic nerve using an ophthalmoscope.
41. A highly successful businessman presents to the community mental health center complaining
of sleeplessness and anxiety over his financial status. What action should the nurse take to
assist this client in diminishing his anxiety?
a. Encourage him to initiate daily rituals.
b. Reinforce the reality of his financial situation.
c. Direct him to drink a glass of red wine at bedtime.
d. Teach him to limit sugar and caffeine intake.
42. What physical assessment data should the nurse consider a normal finding for a
primigravida client who is 12 hours postpartum?
a. Soft, spongy fundus.
b. Saturating two perineal pads per hour.
c. Pulse rate of 56 BPM.
d. Unilateral lower leg pain.
43. The nurse plans to educate a client about the purpose for taking the prescribed antipsychotic
medication clozapine (Clozaril). Which statement should the nurse provide?
a. "It will help you function better in the community."
b. "The medication will help you think more clearly."
c. "You will be able to cope with your symptoms."
d. "It will improve your grooming and hygiene."
44. A male client is admitted to the neurological unit. He has just sustained a C-5 spinal cord
injury. Which assessment finding of this client warrants immediate intervention by the nurse?
a. Is unable to feel sensation in the arms and hands.
b. Has flaccid upper and lower extremities.
c. Blood pressure is 110/70 and the apical pulse is 68.
d. Respirations are shallow, labored, and 14 breaths/minute.
45. A male infant born at 30-weeks gestation at an outlying hospital is being prepared for
transport to a Level IV neonatal facility. His respirations are 90/min, and his heart rate is 150
beats per minute. Which drug is the transport team most likely to administer to this infant?
a. Ampicillin (Omnipen) 25 mg/kg slow IV push.
b. Gentamicin sulfate (Garamycin) 2.5 mg/kg IV.
c. Digoxin (Lanoxin) 20 micrograms/kg IV.
d. Beractant (Survanta) 100 mg/kg per endotracheal tube.
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46. Because the census is currently low in the Obstetrics (OB) unit, one of the nurses is sent to
work on a medical-surgical unit for the day, or until the OB unit becomes busy. Which client
assessment is best for the charge nurse to assign to the OB nurse?
a. An adult who had a colon resection yesterday and has an IV.
b. An older adult who has a fever of unknown origin.
c. A woman who had an acute brain attack (stroke, CVA) 6 hours ago.
d. A teenager with a femoral fracture who is in traction.
47. A primipara at 38-weeks gestation is admitted to labor and delivery for a biophysical profile
(BPP). The nurse should prepare the client for what procedures?
a. Chorionic villi sampling under ultrasound.
b. Amniocentesis and fetal monitoring.
c. Ultrasonography and nonstress test.
d. Oxytocin challenge test and fetal heart rates.
48. A male client who is in the day room becomes increasingly angry and aggressive when he is
denied a day-pass. Which action should the nurse implement?
a. Tell him he can have a day pass if he calms down.
b. Put the client's behavior on extinction.
c. Decrease the volume on the television set.
d. Instruct the client to sit down and be quiet.
49. A client is discussing feelings related to a recent loss with the nurse. The nurse remains silent
when the client says, "I don't know how I will go on." What is the most likely reason for the
nurse's behavior?
a. The nurse is stating disapproval of the statement.
b. The nurse is respecting the client's loss.
c. Silence is reflecting the client's sadness.
d. Silence allows the client to reflect on what was said.
50. An unlicensed assistive personnel (UAP) reports to the charge nurse that a client who
delivered a 7-pound infant 12 hours ago is complaining of a severe headache. The client's
blood pressure is 110/70, respiratory rate is 18 breaths/minute, heart rate is 74 beats/minute,
and temperature is 98.6º F. The client's fundus is firm and one fingerbreadth above the
umbilicus. What action should the charge nurse implement first?
a. Notify the healthcare provider of the assessment findings.
b. Determine if the client received anesthesia during delivery.
c. Assign a practical nurse (PN) to reassess the client's vital signs.
d. Obtain a STAT hemoglobin and hematocrit.
51. In developing a care plan for a client that has a chest tube due to a hemothorax, the
nurse should recognize that which intervention is essential?
a. Keep the arm and shoulder of the affected side immobile at all times.
b. Ensure that there is no fluctuation in the water-seal chamber.
c. Encourage the client to breathe deeply and cough at frequent intervals.
d. Maintain the Pleuravac® slightly above the chest level.
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52. Immediate postoperative nursing care for a client who has had a surgical repair of an
abdominal aortic aneurysm should include which interventions?
a. Assessing pedal pulses frequently and monitoring the nasogastric drainage.
b. Maintaining strict bedrest for 72 hours and assessing radial pulses.
c. Monitoring an infusion of IV heparin and checking the PTT level daily.
d. Assessing the right flank dressing and monitoring the suprapubic Foley catheter.
53. A nurse is teaching a client postoperative breathing techniques using an incentive spirometer
(IS). What should the nurse encourage this client to do to maintain sustained maximal
inspiration?
a. Exhale forcefully into the tubing for 3 to 5 seconds.
b. Inspire deeply and slowly over 3 to 5 seconds.
c. Breathe into the spirometer using normal breath volumes.
d. Perform IS breathing exercises every 6 hours.
54. A 65-year-old female client arrives in the emergency department with shortness of breath and
chest pain. The nurse accidentally administers 10 mg of morphine sulfate instead of 4 mg as
prescribed by the healthcare provider. Later, the client's respiratory rate is 10
breaths/minute, oxygen saturation is 98%, and she states that her pain has subsided. What is
the legal status of the nurse?
a. The nurse is guilty of negligence and will be sued.
b. The client would not be able to prove malpractice in court.
c. The nurse is protected by the Good Samaritan Act.
d. The healthcare provider should have given the morphine sulfate dose.
55. A client with which problem requires the most immediate intervention by the nurse?
a. Finger paresthesias related to carpal tunnel syndrome.
b. Increasing sharp pain related to compartment syndrome.
c. Increasing burning pain related to a Morton's neuroma.
d. Increasing sharp pain related to plantar fascitis.
56. The charge nurse should intervene when what behavior is observed?
a. Two staff members are overheard talking about a cure for AIDS outside a client's
room.
b. A hospital transporter is reading a client's history and physical while waiting
for an elevator.
c. A UAP tells a client, "It's hard to quit drinking but Alcoholic Anonymous
helped me."
d. Two visitors are discussing a hospitalized client's history of drug abuse in the
visitor's lounge.
57. Which assessment finding indicates a client's readiness to leave the nursing unit for a
bronchoscopy?
a. Client denies allergies to contrast media.
b. Skin prep to insertion site completed.
c. On-call sedation administered.
d. Oxygen at 2 L/minute per nasal cannula.
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58. The nurse is planning care for a 16-year-old, who has juvenile rheumatoid arthritis (JRA).
The nurse includes activities to strengthen and mobilize the joints and surrounding muscle.
Which physical therapy regimen should the nurse encourage the adolescent to implement?
a. Exercise in a swimming pool.
b. Splint affected joints during activity.
c. Perform passive range of motion exercises twice daily.
d. Begin a training program lifting weights and running.
59. An 89-year-old male client complains to the nurse that people are whispering behind his back
and mumbling when they talk to him. What age-related condition is likely to be occurring
with this client?
a. Delirium
b. Presbyopia
c. Presbycusis
d. Cerebral dysfunction.
60. A client with a cold is taking the antitussive benzonatate (Tessalon). Which assessment data
indicates to the nurse that the medication is effective?
a. Reports reduced nasal discharge.
b. Denies having coughing spells.
c. Able to sleep through the night.
d. Expectorating bronchial secretions.
61. The community mental health nurse is planning to visit four clients with schizophrenia today.
Which client should the nurse see first?
a. The mother who took her children from school because aliens were after them.
b. The young man who has a history of substance abuse and has no telephone.
c. The newly diagnosed client who needs to be evaluated for
medication compliance.
d. The young woman who believes she is to blame for her recent miscarriage.
62. The nurse is caring for a client whose urine drug screen is positive for cocaine. What behavior
is this client likely to exhibit during cocaine withdrawal?
a. Intense cravings.
b. Increased energy.
c. Talkativeness.
d. Euphoria
63. The nurse enters the room of a client with a history of seizure activity and observes that the
unlicensed assistive personnel (UAP) is securing several pillows against the side rails to
protect the client. What action should the nurse implement?
a. Ensure that the UAP has placed the pillows effectively to protect the client.
b. Instruct the UAP to obtain soft blankets to secure to the side rails instead
of pillows.
c. Assume responsibility for placing the pillows while the UAP completes another
task.
d. Ask the UAP to use some of the pillows to prop the client in a side-lying position.
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64. A 5-year-old child is admitted to the pediatric unit with fever and pain secondary to a sickle
cell crisis. Which intervention should the nurse implement first?
a. Initiate normal saline IV at 50 ml/hr.
b. Administer a loading dose of penicillin IM.
c. Obtain a culture of any sputum or wound drainage.
d. Administer the initial dose of folic acid PO.
65. A client with a compound fracture of the left ankle is being discharged with a below-the-knee
cast. Before being discharged, the nurse should provide the client with what instruction?
a. Keep the left leg in a dependent position.
b. Apply heat to the left leg cast.
c. Do not attempt to scratch the skin under the cast.
d. Apply a cold pack to any "hot spots" on the cast.
66. A client has 2nd degree electrical burns on both upper extremities. The nurse is preparing to
administer the first application of the topical antimicrobial agent mafenide acetate
(Sulfamylon) to the burned area. Which intervention should the nurse implement first?
a. Premedicate the client prior to applying the medication.
b. Use sterile gloves when applying this medication.
c. Cleanse the burned area with sterile normal saline.
d. Assess the client's most recent arterial blood gas test results.
67. The community health nurse must provide a primary prevention program in the community.
Which type of program addresses this need?
a. Provide a nurse-practitioner to prescribe medications for clients with
heart disease.
b. Arrange cardiac-prudent diets to be delivered to individuals using Meals
on Wheels.
c. Incorporate an exercise program at a local Hispanic community center.
d. Conduct a weekly blood pressure screening at the Hispanic senior citizen center.
68. The nurse is conducting assessments at the beginning of the shift. Which client is most likely
to have an increased blood pressure since the last set of vital signs was recorded four hours
ago?
a. A young female with increased urinary output following administration of IV
furosemide (Lasix).
b. A middle-aged male receiving prazosin hydrochloride (Minipress).
c. An elderly male who received two units of packed red blood cells (RBCs).
d. An adolescent who is receiving azathioprine (Imuran) following a
cardiac transplant.
69. A client is hemiplegic following a cerebrovascular accident. To prevent this client from
experiencing a painful shoulder, what intervention should the nurse include in the plan of
care?
a. Exercise the affected shoulder by using it when assisting the client out of bed.
b. Position the affected arm on pillows while the client is seated in a chair.
c. Keep the client's affected arm elevated above the level of the heart.
d. Avoid range of motion exercises on the affected shoulder until pain in the
shoulder has passed.
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70. The pharmacist enters the wrong dose of a medication when transcribing prescriptions to a
client's medication administration record (MAR). Which action should the nurse take to
prevent a medication error from occurring?
a. Compare the medication label with the medication administration record (MAR).
b. Check the client's identification bracelet prior to administering the medication.
c. Compare the medication administration record (MAR) to the prescription.
d. Verify the room number on the medication administration record (MAR).
71. While on the delivery table, a primipara tells the nurse that she wishes to breastfeed her
infant. To assist the new mother with her goal, which intervention is best for the nurse to
implement?
a. Permit privacy for the mother and infant to bond.
b. Assist the mother to elicit a rooting reflex in the infant.
c. Place a small amount of glucose water on the breast.
d. Evaluate the infant's sucking reflex then give the infant to the mother.
72. A male client diagnosed with gastroesophageal reflux (GERD) often wakes up at night
experiencing heartburn. He tells the nurse that he sleeps with the head of the bed on
blocks, and always drinks a glass of milk at bedtime to help him fall asleep. How should the
nurse respond?
a. "Milk does contain tryptophan, which helps many people fall asleep."
b. "Drinking milk before bedtime can increase your symptoms at night."
c. "A warm drink, such as hot tea or cocoa should be substituted for the milk."
d. "Taking an antispasmodic medication with the milk will reduce the symptoms."
73. A client diagnosed with Type 1 diabetes is NPO for a diagnostic test. The nurse is preparing to
administer 24 units of 70/30 insulin. Which intervention should the nurse implement first?
a. Administer the insulin subcutaneously in the client's abdomen.
b. Administer the insulin when the client returns from the test.
c. Contact the healthcare provider to adjust the insulin dose.
d. Call the department and request that this client's test be done first.
74. The nurse teaching a preconception preparation class is discussing ways to improve dietary
folic acid intake. Which evening snack contains the most folic acid?
a. Toasted white bread with butter.
b. Whole grain cereal and milk.
c. Hard-boiled egg and juice.
d. Vanilla milkshake with protein supplement.
75. A 36-year-old client is admitted to the ICU following a six-hour surgery to repair a fractured
pelvis, and the estimated intraoperative blood loss (EBL) was 3,000 ml. Current client data
include: BP 85/70, heart rate 140 beats/minute, urine output 10 ml/hr, PAWP 2, RAP -3, Hct
20%, Hgb 7 g/dl. What action should the nurse take at this time?
a. Administer propranolol (Inderal) to decrease the heart rate.
b. Infuse blood and IV fluids to correct the hypovolemia.
c. Start a dopamine (Intropin) infusion to raise the BP.
d. Draw serum blood cultures to check for infection.
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76. An unresponsive female victim of a motor vehicle collision is brought to the emergency
department where it is determined that immediate surgery is required to save her life. The
client is accompanied by a close friend, but no family members are available. What action
should the nurse take?
a. Notify the unit manager that an emergency court order is needed to allow the
surgery.
b. Continue to prepare the client for the surgery without a signed informed consent.
c. Ask the woman's friend to sign the informed consent since the client is
unresponsive.
d. Maintain continuous monitoring of the client until a family member can be
located.
77. Following a motor vehicle collision, a 3-year-old girl has a spica cast applied. Which toy is best
for the nurse to provide for this 3-year-old child?
a. Set of cloth hand puppets.
b. Barbie doll and clothes.
c. Duck that squeaks.
d. Hand-held video game.
78. While eating at a restaurant, a gravid woman begins to choke and is unable to speak. What
action should the nurse who witnesses the event take?
a. Call 911 immediately then begin cardiopulmonary resuscitation.
b. The Heimlich maneuver using chest thrusts.
c. The Heimlich maneuver using subdiaphragmatic thrusts.
d. Cardiopulmonary resuscitation with uterine tilt.
79. After placing a 36-week-gestation newborn in an isolette and drying the infant with
several blankets, what should the nurse implement next?
a. Open the isolette door to assess the infant's vital signs.
b. Place erythromycin opthalmic ointment in both eyes.
c. Remove the wet blankets and linens from the isolette.
d. Administer the vitamin K (AquaMEPHYTON) injection.
80. A male Muslim client with pneumonia is scheduled to receive a dose of an intravenous
antibiotic but refuses to allow the nurse to begin the medication, stating he cannot allow
fluids to enter his body once he is cleansed for prayer. What action should the nurse
implement?
a. Reschedule administration of the antibiotic until after he completes his prayers.
b. Instruct the client that the antibiotics must be given on time to be effective.
c. Notify the healthcare provider that the client has refused the scheduled antibiotic.
d. Ask the pharmacist to supply an oral form of the antibiotic for the client.
81. The nurse learns that a newly admitted adult client has a six month history of recurring
somatic pain. During the admission interview, it is most important for the nurse to question
the client about what problem ?
a. Episodes of tremors.
b. Feelings of depression.
c. Periods of restlessness.
d. Nausea and vomiting.
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82. The nurse administers nalbuphine (Nubain) to a postoperative client. What etiology,
secondary to the medication's effects, places the client at risk for injury?
a. Bleeding complications.
b. Adverse CNS effects.
c. Electrolyte imbalance.
d. Immune system suppression.
83. A client who has end-stage renal disease (ESRD) continues to be despondent after receiving the
biologic response modifier (BRM) epoetin alfa (Epogen, Procrit) for 3 weeks. Which
parameters should the nurse assess when evaluating the effectiveness of this BRM?
a. WBCs, neutrophil and T4 count.
b. RBCs, hemoglobin, and hematocrit.
c. Blood pressure, heart rate, and temperature.
d. Serum potassium, calcium, and phosphorus.
84. A 25-year-old male client has a diagnosis of epididymitis and a positive culture for Escherichia
coli. What is the most important information for the nurse to include in the teaching plan?
a. Avoid penile contact with the rectal area.
b. Epididymitis is a pre-cancerous condition.
c. Obtain an annual prostate digital exam.
d. Surgical intervention is often indicated.
85. A client is admitted to the hospital with a serum sodium level of 128 mEq/L, distended
neck veins, and lung crackles. What intervention should the nurse implement?
a. Increase the intake of salty foods.
b. Administer NaCl supplements.
c. Restrict oral fluid intake.
d. Hold the client's loop diuretic.
86. A young adult male is brought to the emergency room with multiple gunshot wounds in the
chest, abdomen, and head. After collecting the client's blood-saturated clothing as forensic
evidence for the medical examiner, which action should the nurse implement?
a. Fold clothing in a large specimen container and send to the pathology lab.
b. Roll the clothing in a towel and cover it with an impermeable drape.
c. Place the clothes in a paper bag and transfer bag to a red biohazard bag.
d. Drop the clothes in a red plastic bag and maintain blood-borne precautions.
87. A male client asks the nurse how long his hospital stay will be following his scheduled surgery.
Which resource provides the best guide for the nurse in responding to the client?
a. Critical pathway for the scheduled surgery.
b. Diagnosis-related group (DRG) for the surgery.
c. The client's preferred provider arrangement.
d. Standards of clinical nursing practice.
88. A client diagnosed with dementia is disoriented, wandering, has a decreased appetite, and is
having trouble sleeping. What is the priority nursing problem for this client?
a. Disturbed thought processes.
b. Altered sleep pattern.
c. Imbalanced nutrition: less than.
d. Risk for injury.
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89. The nurse-preceptor is orienting a new graduate nurse to the critical care unit. The preceptor
asks the new graduate to state symptoms that most likely indicate the beginning of a shock
state in a critically ill client. What findings should the new graduate nurse identify?
a. Warm skin, hypertension, and constricted pupils.
b. Bradycardia, hypotension, and respiratory acidosis.
c. Mottled skin, tachypnea, and hyperactive bowel sounds.
d. Tachycardia, mental status change, and low urine output.
90. Prior to obtaining an axillary temperature, the nurse should perform which action?
a. Check the last oral temperature reading.
b. Ask the client when he last ate or drank.
c. Place a protective sheath over the thermometer.
d. Position the client's arm at heart level.
91. When is the best time for the nurse to assess a client for residual urine?
a. When the client's bladder is distended.
b. Immediately after the client voids.
c. Just prior to the client voiding.
d. After draining the urinary catheter bag.
92. Which finding should raise the greatest concern for a nurse who is performing an ENT
examination?
a. A painful ulcerated mucosal area inside the cheek for 1 day.
b. Stippled gingival margins that adhere firmly to the teeth.
c. A number of small yellowish-white and raised lesions on the buccal mucosa.
d. An ulceration under the tongue that has been present for the last three weeks.
93. During a home visit, the nurse should evaluate the adequacy of a client's treatment for COPD
by assessing for which primary symptom?
a. Dyspnea
b. Tachycardia.
c. Unilateral diminished breath sounds.
d. Edema of the ankles.
94. The community health nurse is working in a multi-ethnic health center. In what situation
should the nurse intervene?
a. An Asian-American mother reports using cupping to treat infection, resulting in
a pattern of red round marks on her toddler's back.
b. A Hispanic pregnant client who is often late for appointments, arrives late for
today's appointment.
c. A Native-American who is being interviewed will not make direct eye
contact when asked about violence in the home.
d. An African-American infant who is spitting up milk has lost 6 ounces since last
week's clinic visit.
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95. When assessing a male client who is receiving a unit of packed red blood cells (PRBCs), the
nurse notes that the infusion was started 30 minutes ago, and 50 ml of blood is left to be
infused. The client's vital signs are within normal limits. He reports feeling "out of breath"
but denies any other complaints. What action should the nurse take at this time?
a. Administer a PRN prescription for diphenhydramine (Benadryl).
b. Start the normal saline attached to the Y- tubing at the same rate.
c. Decrease the intravenous flow rate of the PRBC transfusion.
d. Ask the respiratory therapist to administer PRN albuterol (Ventolin.).
96. The nurse observes that a client has received 250 ml of 0.9% normal saline through the IV line
in the last hour. The client is now tachypneic, and has a pulse rate of 120 beats/minute, with a
pulse volume of +4. In addition to reporting the assessment findings to the healthcare
provider, what action should the nurse implement?
a. Discontinue the IV and apply pressure at the site.
b. Decrease the saline to a keep-open rate.
c. Increase the rate of the current IV solution.
d. Change the IV fluid to 0.45% normal saline at the same rate.
97. A client who participates in a health maintenance organization (HMO) needs a bone marrow
transplant for treatment of breast cancer. The client tells the nurse that she is concerned that
her HMO may deny her claim. What action by the nurse best addresses the client's need at
this time?
a. Have the client's healthcare provider write a letter to the HMO explaining
the need for the transplant.
b. Help the client place a call to the HMO to seek information about limitations of
coverage.
c. Encourage the client to call a lawyer so that a lawsuit can be filed against
the HMO if necessary.
d. Have the social worker call the state board of insurance to register a
complaint against the HMO.
98. The charge nurse observes that a client with a nasogastric tube applied to low
intermittent suction is drinking a glass of water immediately after the unlicensed
assistive personnel
a. Remove the glass of water and speak to the UAP.
b. Discuss the incident with the UAP at the end of the day.
c. Write an incident report and notify the healthcare provider.
d. Remind the client of the potential for electrolyte imbalance.
99. Which assessment is most important for the nurse to complete to determine a client's tolerance
for ambulation?
a. Respiratory rate.
b. Capillary refill.
c. Pedal pulses.
d. Skin turgor.
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100. A female client with bulimia is admitted to the mental health unit after she disclosed to a
friend that she purges after meals. Which intervention should the nurse implement
first?
a. Provide a supportive, structured environment for meals.
b. Assess weight, vital signs, potassium and other electrolytes.
c. Discuss alternative strategies for binging and purging.
d. Monitor the client after meals for possible vomiting.
101. Which symptom in a client with fractured ribs would indicate the presence of an
abnormality warranting immediate intervention by the nurse?
a. Complaints of chest pain with movement.
c. Shallow respirations and refusing to take deep breaths.
b. Ecchymosis around fracture site.
c. Asymmetrical chest wall excursion.
102.
A 62-year old male client with a history of coronary artery disease complains that his heart is
"racing" and he often feels dizzy. His blood pressure is 110/60, and he uses portable oxygen at
2 liters per nasal cannula. Based on the rhythm shown, the nurse should administer which
prescription?
a. Give magnesium per secondary infusion.
b. Initiate IV heparin solution per protocol.
c. Administer IV adenosine (Adenocard).
d. Prepare for synchronized cardioversion.
103. The mental health nurse observes that a female client with delusional disorder carries some
of her belongings with her because she believes that others are trying to steal them. Which
nursing action will promote trust?
a. Explain that distrust is related to feeling anxious.
b. Initiate short, frequent contacts with the client.
c. Explain that these beliefs are related to her illness.
d. Offer to keep the belongings at the nurse's desk.
104. A client in acute renal failure has a serum potassium level of 6.3 mEq/L. What medication can
the nurse expect the healthcare provider to prescribe?
a. Nitrofurantoin (Macrodantin) orally.
b. Erythropoietin (Epogen) intravenously.
c. Kayexalate retention enema.
d. Azathioprine (Imuran) orally.
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105. A client with late stage rheumatoid arthritis frequently drops the silverware while eating.
Which resource would be of greatest value to this client?
a. A UAP to help feed the client.
b. An Occupational Therapist.
c. A Physical Therapist.
d. A Registered Dietician.
106. The mother of a one-month-old calls the clinic to report that the back of her infant's head
is flat. How should the nurse respond?
a. Place a small pillow under the infant's head while lying on the back.
b. Turn the infant on the left side braced against the crib when sleeping.
c. Prop the infant in a sitting position with a cushion when not sleeping.
d. Position the infant on the stomach occasionally when awake and active.
107. During a preoperative appointment at an ambulatory surgery center, a client
expresses anxiety to the nurse about the impending surgery. How should the nurse
respond?
a. "It is very normal to feel anxious before a surgical procedure."
b. "Let me sit down with you and explain the surgical procedure."
c. "Tell me what concerns you have about your upcoming surgery."
d. "Medication will be available if you experience any pain after surgery."
108. The nurse is planning to administer a Mantoux test to determine if the client has been
infected with the tuberculosis bacilli. What is the correct interpretation by the nurse?
a. A positive reaction indicates that active disease is present in the body.
b. The test should be read within 24 hours of administration.
c. Induration noted by inspection and palpation confirms a significant reaction.
d. A reaction of 0 to 4 mm is considered significant and requires
further investigation.
109. The nurse is communicating with a 12-year-old who is hearing impaired. What action is
best for the nurse to use when attempting to communicate with this child?
a. Convey ideas by writing short sentences.
b. Emphasize emotions with facial expressions.
c. Attract the child's attention before speaking.
d. Use a picture board to communicate needs.
110. The nurse anticipates the prescription of a reduced dosage of a nephrotoxic medication for
the client with which problem?
a. Documented presence of a kidney cyst found via ultrasound.
b. Observable hematuria following a renal biopsy procedure.
c. Subjective reports of dysuria with burning pain and cloudy amber urine.
d. Diminished creatinine clearance found after 24-hour urine collection.
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111. The nurse is assessing a client's central venous pressure (CVP) via a pulmonary artery (PA)
catheter port. The client is in a supine position with the head of the bed at a 45 degree angle.
The CVP reading is 6 mmHg higher than the previous reading. To evaluate the reading, what
action should the nurse take first?
a. Verify the recorded bed position of the last reading.
b. Evaluate the client's 24 hour intake and output.
c. Reposition the client and reassess the reading.
d. Report the pressure to the healthcare provider.
112. While inserting an indwelling urinary catheter in a female client, the nurse observes urine
flow in the tubing. What action should be taken next?
a. Document the color and clarity of the urine.
b. Insert the catheter an additional inch.
c. Inflate the balloon with 5 ml of sterile water.
d. Ask the client to breathe deeply and slowly exhale.
113. The first time a male client stands at the bedside following a total hip replacement, he
reports severe pain in his left calf. What intervention should the nurse take first?
a. Remind the client of the importance of postoperative mobility.
b. Use a pain scale to evaluate the severity of the pain.
c. Return the client to bed and assess the lower extremities.
d. Transfer the client to a chair and elevate the lower extremities.
114. A 10-year-old boy is admitted to Neuro Intensive Care following a supratentorial craniotomy.
What postoperative intervention should the nurse plan to implement?
a. Elevate the client's head of bed to 30 degrees.
b. Teach the child about patient controlled analgesia (PCA).
c. Administer IV D5 / 0.25 NS via pump at 125 ml/hr.
d. Remove the surgical dressing to assess for bleeding.
115. Which finding in an elderly female client who was started on digoxin (Lanoxin) 0.25
mg indicates that the medication is producing a therapeutic effect?
a. Increased heart rate.
b. Decreased cardiac output.
c. Increased kidney perfusion.
d. Decreased cerebral perfusion.
116. The nursing diagnosis, "High risk for infection" is most relevant for a client with
which hematologic problem?
a. Agranulocytosis
b. Thrombocytopenia.
c. Erythrocytopenia.
d. Polycythemia.
117. The alarm of a client's pulse oximeter sounds and the nurse notes that the oxygen
saturation rate is indicated at 85%. What action should the nurse take first?
a. Check the probe position.
b. Administer oxygen by face mask.
c. Notify the healthcare provider.
d. Reset the alarm.
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118. A client admitted to the hospital is suspected of having meningitis. The nurse should plan to
prepare the client for which diagnostic test?
a. Synovial fluid analysis.
a. Synovial fluid analysis.
b. Lumbar puncture.
c. Electroencephalogram (EEG).
d. Cervical x-rays.
119. Following a traumatic delivery, an infant receives an initial Apgar of 3. What intervention is
most important for the nurse to implement?
a. Continue resuscitative efforts.
b. Inform the parents of the infant's condition.
c. Repeat the Apgar assessment in 5 minutes.
d. Page the pediatrician STAT.
120. After administering the initial dose of enalapril (Vasotec) to a female client, it is
most important for the nurse to assist the client with which activity?
a. Ambulation in the room and hallway.
b. Feeding the client her next meal.
c. Cough and deep breathing exercises.
d. Mouth and skin care measures.
121. The charge nurse working on a rehabilitation unit is making client assignments for 2
registered nurses (RN) that have been in the department over 3 years, and one new RN
graduate who completed orientation this week. Which client should the charge nurse assign to
the new RN graduate? The client
a. with a T-12 spinal cord injury who is being transferred from the neurological unit.
b. with a head injury who is being discharged home with multiple referrals.
c. whose family is meeting with the rehabilitation team to discuss a treatment plan.
d. with a total knee replacement who has 3 hours of prescribed physical therapy.
122. A client has a new prescription for the maximum recommended dosage of
piperacillin/tazobactam (Zosyn) for nosocomial pneumonia. The nurse should report which
laboratory finding to the healthcare provider before administering the prescribed dose?
a. Presence of gram positive bacteria in the sputum.
b. Elevated white blood cell count.
c. Decreased creatinine clearance.
d. Decreased serum potassium.
123. In teaching a client with Parkinson's disease, the nurse describes what rationale for
the prescription of levodopa-carbidopa (Sinemet)? This drug
a. acts as an antiseizure medication, reducing the tremors caused by the disease.
b. increases the amount of dopamine, needed for muscles to function correctly.
c. slows the scarring in the myelin sheath, improving muscle tone and strength.
d. reduces the inflammatory process, improving nerve transmission and function.
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124. A male client who has been immobilized for four days because of multiple broken bones
following a motor vehicle collision is admitted from the intensive care unit to the medical unit
of an acute care hospital. What assessment data are most important for the nurse to obtain
within the first hour of admission?
a. Skin integrity and nutritional status.
b. Tolerance for moving in bed and performing ROM exercises.
c. Blood pressure and white blood cell count.
d. Temperature and breath sounds.
125. Which finding should the nurse expect a client to exhibit who is newly diagnosed
with fibromyalgia?
a. Recent joint trauma.
b. Disruption in sleep patterns.
c. Unexplained weight gain.
d. Itching and rash.
126. An alert and oriented client requiring droplet precautions is placed in a private room at the
end of the hallway. Several days later, the nurse finds that the client is restless and anxious.
What action should the nurse implement?
a. Transfer the client to a semi-private room closer to the nurse's station.
b. Encourage family members to maintain a regular visitation schedule.
c. Advise unit personnel to enter the client's room only when necessary.
d. Obtain a prescription for a vest restraint from the healthcare provider.
127. The nurse is performing an admission assessment on an HIV positive client with a diagnosis
of Pneumocystis carinii pneumonia (PCP). The nurse should carefully observe the client for
which symptoms?
a. Weight loss exceeding 10 percent of baseline body weight.
b. Creamy white patches in the oral cavity.
b. Altered mental status and tachypnea.
c. Normal ABGs, with wet lung sounds in all lung fields.
128. A 3-year-old with HIV infection is staying with a foster family who is caring for three other
foster children in their home. When one of the children acquires pertussis, the foster mother
calls the clinic and asks the nurse what she should do. Which action should the nurse take
first?
a. Review the immunization documentation of the child with HIV.
b. Report the exposure of the child with HIV to the Health Department.
c. Remove the child who has HIV from the foster home.
d. Place the child who has HIV in reverse isolation.
129. The healthcare provider prescribes an excessive amount of morphine sulfate IV push to be
given to a terminally ill client. What is the priority intervention for the nurse to
implement?
a. Refuse to administer the medication.
b. Report the prescription to the medical director.
c. Report the incident to the medical ethics committee.
d. Obtain permission from the family prior to administering.
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130. A 2-year-old child with celiac disease experiences a relapse of symptoms. In developing a
teaching plan for the child's family, which topic should be the nurse's primary focus?
a. Dietary management.
b. Chronic disease adaptation.
c. Perianal skin care.
d. Disease complications.
131. Which client situation requires the most immediate intervention by the nurse?
a. A six centimeter area of reactive hyperemia is observed over the left trochanter
of a bedfast client.
b. A four centimeter area of dehiscence is observed on a client's abdominal incision
one day after surgery.
c. A stage II pressure ulcer located on a client's sacrum is draining a
moderate amount of purulent drainage.
d. A stage IV pressure ulcer has a five centimeter area of necrosis surrounded
by pale pink tissue.
132. A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the
pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe
and pierced the bottom of the child's foot. Which action should the nurse implement first?
a. Cleanse the foot with soap and water and apply an antibiotic ointment.
b. Provide teaching about the need for a tetanus booster within the next 72 hours.
c. Have the mother check the child's temperature q4h for the next 24 hours.
d. Transfer the child to the emergency department to receive a gamma globulin
injection.
133. An 84-year-old female resident of an assisted living center has become increasingly withdrawn
from her friends, cries often, and asks the nurse to call her daughter three times a day. The
nurse's plan of care should be based on the knowledge that the resident is exhibiting behaviors
consistent with which of Erikson's stages?
a. Satisfaction vs. Depression.
b. Integrity vs. Despair.
c. Trust vs. Mistrust.
d. Intimacy vs. Isolation.
134. The nurse assesses an adult client who has a sigmoid colostomy following a bowel
exploration performed yesterday. Which assessment finding should be reported to the
surgeon immediately?
a. The fecal matter is brown and has a solid consistency.
b. The stoma mucosa is purple in color.
c. The stoma has streaks of bright red blood.
d. There are no bowel sounds in the left lower quadrant.
135. A client with fluid volume excess has gained 6.6 pounds. The nurse recognizes that this
is equivalent to what volume of fluid?
a. One-half liter.
b. One liter.
c. Two liters.
d. Three liters.
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136. The charge nurse is making client assignments in the Intensive Care Department. The
healthcare team consists of one registered nurse (RN) with 10 years experience, one RN with 5
years experience, and a new graduate RN who just completed a 12-week internship. Which
client should the nurse assign to the new graduate RN?
a. A client in end-stage liver failure who is experiencing esophageal bleeding.
b. A client with multisystem failure secondary to a motor vehicle collision.
c. A client with chest tubes secondary to a stab wound to the chest.
d. A client with Adult Respiratory Distress Syndrome who is on a ventilator.
137. The mental health nurse working in a community treatment center is preparing an
educational presentation on medication administration, and plans to use photographs of clients
to demonstrate certain medication principles. Which intervention is most important for the
nurse to implement?
a. Identify which psychotropic medications will be used in the presentation.
b. Determine if the clients have allergies to the medications being demonstrated.
c. Obtain written consent from each client to take their personal picture.
d. Assess the client's understanding of why the presentation is being prepared.
138. The nurse enters a male client's room to administer a subcutaneous dose of enoxaparin
sodium (Lovenox), a low molecular weight heparin. The client is lying supine in bed. What
action should the nurse implement?
a. Roll up the sleeve of the client's hospital gown to fully expose his upper arm.
b. Elevate the head of the bed and look for any bruising around the umbilicus.
c. Ask the client if he can tolerate lying on his abdomen for a short period of time.
d. Observe the sides of the client's abdomen while he remains in a supine position.
139. A high-school girl asks the school nurse what to do about her fingernails that look "so awful"
since she had her artificial nails removed 6 weeks ago. On inspection, the nurse finds the girl's
nails are thickened, cracked, and yellowing. What instruction should the nurse provide?
a. Do not use manicure products that dry the nails.
b. Use a prescribed systemic antifungal medication.
c. Keep nails short and trimmed straight across.
d. Avoid harsh chemicals and abrasives on the nails.
140. The nurse identifies a priority diagnosis of, "Altered comfort related to menstrual cramps" for
a 25-year-old female client. Which self-care activity should the nurse emphasize in the client's
teaching plan?
a. Regular aerobic exercise.
b. Weight-bearing activities.
c. Abdominal wall strengthening.
d. Pelvic floor exercises.
141. A client receiving warfarin (Coumadin) develops hematuria. What is the priority nursing
action?
a. Obtain a urine specimen for urinalysis.
b. Instruct the client to increase oral fluid intake.
c. Monitor the client's serum prothrombin time/INR.
d. Assess the next bowel movement for occult blood.
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142. While making a home visit, the nurse observes that a male client who is on a sodium restricted
diet is drinking herbal tea and using a salt substitute to flavor his breakfast of scrambled eggs
and smoked ham. What instruction should the nurse provide?
a. Replace the ham with toast and jelly.
b. Substitute mixed fruit for the eggs.
c. Avoid daily use of the salt substitute.
d. Drink orange juice instead of herbal tea.
143. While administering a pneumococcal vaccine to an older adult, the nurse provides
teaching about methods to prevent pneumonia. Which instruction should the nurse
include?
a. Engage in regular leg exercises while sitting.
b. Enroll in a smoking cessation program.
c. Take a small dose of aspirin daily.
d. Adhere to a low sodium diet.
144. A male client with chronic pain reports minimal pain relief despite attempts to adhere to the
pain relief measures he was taught. He appears withdrawn and refuses to be involved with
planning his care. The nurse should identify which problem as having the highest priority?
a. Hopelessness.
b. Self-care deficit.
c. Knowledge deficit.
d. Noncompliance.
145. The nurse is supervising an unlicensed assistive personnel (UAP) who is preparing to
provide catheter care for a client with an indwelling urinary catheter. The UAP has
obtained sterile gloves and the supplies needed to clean the area. What action should the
nurse take?
a. Advise the UAP that exam gloves can be used rather than sterile gloves.
b. Assign the UAP to another task while the nurse completes the procedure.
c. Acknowledge that the UAP is well prepared to maintain aseptic technique.
d. Assist the UAP in setting up the sterile field before the procedure is started.
146. The RN case-manager working in a home health care agency is making client
assignments. Which client should the case-manager assign to a newly hired RN with 3
years acute care experience? The client
a. diagnosed with heart failure who needs an admission assessment.
b. who needs an intravenous antibiotic via a subclavian line.
c. who is being discharged from home health care after 3 months.
d. who is requesting information about a hospice referral.
147. A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency room with
the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding
should the nurse expect this client to exhibit?
a. Hypotension and venous pooling in the extremities.
b. Profuse diaphoresis and severe, pounding headache.
c. Complaints of chest pain and shortness of breath.
d. Pain and a burning sensation upon urination and hematuria.
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148. A primigravida client being treated for preeclampsia with magnesium sulfate delivered a
7-pound infant four hours ago by cesarean delivery. Which nursing diagnosis has the highest
priority?
a. Risk for injury related to uterine atony.
b. Ineffective breastfeeding related to fatigue.
c. Impaired parenting related to inexperience.
d. Acute pain related to abdominal incision.
149. A male client's lithonate (Lithium) prescription was increased a month ago, and his current
lithium level is 0.54 mEq/L. When calling the client to report the laboratory findings, which
question is most important for the nurse to ask?
a. "Have you been taking your lithium every day?"
b. "Are you having any side effects from the lithium?"
c. "Do you have any concerns about your lithium?"
d. "Are you willing to have another lithium level done?"
150. The nurse is pouring a bottle of sterile solution into a container on a sterile field that is set up
on a client's bedside table. Which action is in keeping with the principles of surgical
asepsis?
a. Avoid spilling or splashing the solution when pouring.
b. Apply sterile gloves prior to pouring the solution.
c. Remove the solution cap and place it on the sterile field.
d. Place the bottle of solution behind the sterile container.
151. A client who had a left above knee amputation (AKA) two days ago has a soft stump
dressing in place. To prevent the development of a contracture on the left leg, which
intervention should the nurse implement?
a. Elevate the client's left leg on two pillows at all times.
b. Instruct the client to push the stump against a soft pillow.
c. Position the client prone 3 to 4 times a day.
d. Turn the client to the unaffected side only.
152. The nurse overhears two hospital employees discussing confidential client information in
the cafeteria. The nurse decides to intervene, because this situation is a breach of which
ethical principle?
a. Veracity
b. Consistency.
c. Autonomy
d. Fidelity.
153. A middle-aged female client is admitted to the Emergency Department after fainting while
working outside and perspiring on a hot summer day. Assessment findings indicate that she is
tachycardic with a blood pressure of 96/68, and her serum sodium level is 128 mEq/L. Which
prescription should the nurse implement first?
a. Insert indwelling catheter.
b. Normal saline IV at 125 ml/hour.
c. Continuous telemetry.
d. Obtain a cerebral CAT scan today.
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154. Following a total thyroidectomy, the nurse plans to observe a client for complications; in
particular, for development of hypoparathyroidism. What finding indicates that the client has
developed this complication?
a. Complains of back and joint tenderness and pain.
b. Complains of muscle twitching in hands and feet.
c. Denies muscle spasms in extremities.
d. Diaphoretic, but denies any headache.
155. A 30-year-old female client with a history of fibrocystic breast disease is seeking care because
of a pea-sized, painful lump she discovered in her left breast three weeks ago. She is anxious,
and states that she is sure she has cancer. Which response is best for the nurse to provide?
a. "Don't worry, this is probably not cancer because the lump is small and painful."
b. "It could be cancer. We won't know until you see a surgeon and a biopsy can be
performed."
c. "Your risk of cancer is low, but you did the right thing coming in to seek more
information."
d. "With your history, you should have sought follow-up assessment as soon as you
noticed the lump."
156. A highly successful businessman presents to the community mental health center
complaining of sleeplessness and anxiety over his financial status. What action should the
nurse take to assist this client in diminishing his anxiety?
a. Encourage him to initiate daily rituals.
b. Reinforce the reality of his financial situation.
c. Direct him to drink a glass of red wine at bedtime.
d. Teach him to limit sugar and caffeine intake.
Completion
Complete each sentence or statement.
157. Ampicillin (Ampicin) 1 gram IV q4h is prescribed for a 38 week multipara how is positive for
Group B streptococcus. The drug is available via the Ptyxis system diluted in 50 ml of normal
saline. To admister the medication over 30 minutes, the nurse should set the infusion pump to
deliver how many ml/hr? (Enter numerical value only)
158. A client weighing 176 pounds is started on a weight-based heparin protocol. The pharmacy
provides 500 ml D5W with 25,000 units of heparin. The sliding scale prescription reads:
"Begin the infusion for the client weighing 74-80 kg to infuse at 1000 units/hr; more than 80 kg
infuse at 1,200 units/hr; less than 74 kg infuse at 800 ml/hr." The nurse should regulate the
infusion pump at how many ml/hour? (Enter numerical value only.)
159. The nurse plans to administer two preoperative medications to a client in a single syringe. The
prescription is for meperidine (Demerol) 75 mg and promethazine (Phenergan) 25 mg. The
Demerol is contained in a vial labeled 100 mg/ml, and the Phenergan is in a vial labeled, "25
mg/ml." How many total ml will the syringe contain that the nurse administers to this client?
(Enter numerical value only. If rounding is required, round to the nearest hundredth.)
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160. A 16-year-old male is admitted after a motor vehicle collision with 50% burns over his body.
One liter of normal saline is prescribed to infuse over 4 hours. The drop factor is 60 drops per
ml. The nurse should regulate the infusion to administer how many drops per minute?
(Enter numerical value only.)
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ID: A
TEST 1
Answer Section
MULTIPLE CHOICE
1. ANS: C
Signs of chronic arterial insufficiency include decreased hair growth in the legs and feet,
absent or decreased pedal pulses, infection in the foot, poor wound healing, thickened nails,
and a shiny appearance of the skin (C). Femoral pulses (A) should still be palpable in the
diabetic with chronic arterial insufficiency. A positive Homan's sign is an indicator of deep
vein thrombosis (B). (D) would probably not be affected significantly by chronic arterial
insufficiency.
2. ANS: C
4 lbs / 2.2 = 1.8 kg. 1.8 x 15 = 27 mg (C).
NOTE, the fact that the drug is diluted in 25 ml of D5W, is not relevant to the calculation
requested.
3. ANS: C
The client is exhibiting symptoms of magnesium sulfate toxicity--decreased reflexes (normal is
+2), a low normal respiratory rate (normal is 12 to 20 breaths/min), a less than average
urinary output (30 ml/hour is average), and a low magnesium sulfate level (normal is 4 to
8mg/dl). Based on these findings, the nurse should stop the infusion (C). (A) is
contraindicated. (B) would not fully alleviate the magnesium sulfate toxicity symptoms. (D)
(the antagonist for magnesium sulfate) would be indicated if the respiratory rate were less
than 12 breaths/minute.
4. ANS: A
This medication causes paralysis (A) following intravenous injection. Peak effects persist for
35 to 60 minutes. (B and C) would not be possible if the medication is effective. The Glasgow
coma scale is used to evaluate the neurological status of the client and does not evaluate the
effectiveness (D) of this medication.
5. ANS: B
Frequent and/or large doses of acetaminophen can cause an increase in liver enzymes,
indicating possible liver damage (B). If the client reported unusual bleeding, or an increase in
aspirin usage, it would be important for the nurse to assess for increased bleeding and monitor
(A and/or C). (D) is not affected by increases in acetaminophen doses.
6. ANS: C
Ringing in the ears (tinnitus) (C) is an important sign of aspirin overdosage and should be
reported immediately. Though a tepid sponge bath may lower the child's temperature, the
prescription for aspirin should not be held (A). Aspirin should be taken with at least eight
ounces of water to completely wash the tablet into the stomach and to help prevent GI
discomfort (B). Yellow halos are associated with Digoxin toxicity, not aspirin (D).
1
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7. ANS: D
The classic picture of Cushing's syndrome in the adult is central-type obesity with thin
extremities (D), along with a "buffalo hump" in the supraclavicular area, heavy trunk, and
thin fragile skin. The symptoms described in (A) are clinical manifestations of
hypothyroidism, and in (B) of hyperthyroidism. (C) may indicate a goiter or a tumor of the
thyroid gland.
8. ANS: D
A pulse oximeter reading of 90% indicates an arterial blood gas of less than 80 to 100 and
should be assessed immediately (D). (A) is an expected finding. (B) is not an unusual finding.
(C) is an expected finding for this client.
9. ANS: A
Client behaviors indicating that the expected outcome of, "decreased venous congestion" has
been met would include elevating the legs, increasing walking time, and an observable
decrease in edema of the lower extremities (A). (B and C) would be appropriate for outcomes
for, "Attains or maintains tissue integrity." (D) would be an appropriate outcome for,
"Demonstrates an increase in arterial blood supply to extremities."
10. ANS: D
Life-threatening complications such as hypovolemia and sepsis can occur following a
paracentesis, and measurement of vital signs (D) will provide assessment data that will help
detect the occurrence of such complications. (A) might be assessed to check for circulation in
the lower extremities, but are not indicated for postparacentesis assessment. Reduction of (B)
may occur as the result of decreased fluid in the peritoneal cavity, but is a desired outcome,
not a complication, of this procedure. (C) is not affected by a paracentesis procedure.
11. ANS: B
RenaGel is an intestinal phosphate binder and should be taken with meals to prevent
contributing to the hyperphosphatemia (B), associated with ESRD. (A, C, and D) are not the
therapeutic actions of RenaGel.
12. ANS: B
The client with myasthenia gravis experiences fatigue and muscle weakness, which is likely
to result in a diminished cough effort (B). (A, C, and D) are not common in clients with
myasthenia gravis.
13. ANS: A
The nurse should question the administration of a tube feeding into the GI tract (A), which may result
in vomiting and aspiration, because the client is exhibiting signs of decreased peristalsis and
possible bowel obstruction. (B) provides a means of safely providing nutrition while GI tract function
is inhibited. (C) benefits the client by reducing any excess gastric contents. (D) helps stimulate
peristalsis.
14. ANS: D
The client would have no palpable pulse (D), because ventricular fibrillation is chaotic
electrical activity which does not produce cardiac output. This is a medical emergency which
requires immediate treatment to prevent death. (A, B, and C) are not typical of pulses in
ventricular fibrillation.
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15. ANS: D
Angular stomatitis at the corners of the mouth is caused by poor dietary intake of vitamin B2
(riboflavin) and B6 (pyridoxine) (D). (A) would irritate them. Although a vitamin C
supplement would be beneficial, (B) would burn the client's mouth and make her less likely to
eat. The client is not likely to have an infection, but if the cracks at the corners of her mouth
do become infected, antibiotics in the form of a cream would be more appropriate (C).
16. ANS: C
Even if the client has not been seriously hurt, she has been inconvenienced by the incident and
it is appropriate for her to be angry. The nurse can clarify the client's feelings (C). (A) is a
barrier to communication and shames the client for feeling angry. (B) changes the subject and
does not address the client's anger--even minor car repairs can cause major inconveniences.
(D) does not address the client's feelings and may bring up unpleasant memories the
client does not wish to share at this time.
17. ANS: C
The resident may feel isolated and is likely to be demonstrating his unmet need for touching
(C). Often older men are wrongly accused of sexual advances when they demonstrate needs
for touch (A). The UAP needs to be taught appropriate means of handling the situation, but
(B) is avoiding the situation and is not a good management technique. The resident should not
be given consequences when he has not done anything seriously wrong (D).
18. ANS: B
Hypospadias repair is often done between 6 and 18 months, depending on the repair needed
and whether it is done in one or two stages. Psychologically, it helps the child and parents if
the repair is done prior to the child having genital awareness and is standing to urinate (B).
(A) may occur, but infants tolerate anesthesia better after 6 months of age. (C and D) can have
psychological effects related to issues of body-image and self-concept.
19. ANS: A
A Holter monitor is a continuous recording device designed to detect dysrhythmias during
ADLs. The client should keep a diary of activity, noting the time of any symptoms,
experiences, or unusual activities performed (A). The client should perform normal activities
(B). Blood samples are not routinely drawn (C). A Holter monitor will not be affected by a
microwave oven (D).
20. ANS: B
Polydipsia (B), polyuria, and polyphagia are key signs of diabetes in children and adults. (A
and C) are not associated with diabetes in children. (D) is not usually characteristic of
diabetes in children, but is associated with diabetes in adults.
21. ANS: B
The nurse should determine the availability of packed red blood cells for Client B (B)
because the low hemoglobin during the postoperative period indicates the probable need for
a blood transfusion. (A) would eliminate Client A's hypoxic drive that creates the urge to
breathe, resulting in a respiratory arrest. Client C's potassium is within normal limits, and
(C) will only help to maintain this level. Client D's elevated WBC is expected during the acute
infectious process of an appendicitis attack and would not delay the surgery (D).
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22. ANS: C
Contacting someone (C) of the client's choosing helps to maintain her confidentiality since she
chooses the person to remove the weapon, but also ensures safety in that the gun is removed by
another person. (A) is not as safe an intervention as having someone else remove the weapon.
The healthcare provider must be notified of any suicidal ideation regardless of the severity of
the ideation (B), but safety has a higher priority than communication with the healthcare
provider. (D) violates the client's confidentiality and, though safety is a higher priority than
confidentiality, (C) provides both.
23. ANS: A
Access of an implanted port is a skill that requires experience and expertise, so it is important
for the RN to supervise a graduate nurse performing this task (A). An experienced nurse
should be able to start a blood transfusion (B) regardless of the setting, and should not require
direct supervision. The practical nurse should be able to assist with a procedure such as a
lumbar puncture (C) without direct supervision, and the UAP (D) can perform this skill
without direct supervision.
24. ANS: D
The nurse needs to obtain information about the client's specific reaction to the agent (D) to
determine whether an allergy exists or whether the reaction is a medication side effect. (A, B,
and C) have little relevance to obtaining pertinent information for this client's health history.
25. ANS: A
A decreased urine specific gravity (A) often occurs with diabetes insipidus because the
antidiuretic hormone is not present to promote reabsorption from the kidneys. The kidneys
fail to concentrate urine, resulting in excretion of large amounts of dilute urine. (B) is not
found with diabetes insipidus, as it is with diabetes mellitus. (C and D) can occur with a
variety of conditions, including diabetes insipidus, but they are not particularly indicative of
diabetes insipidus, as is (A).
26. ANS: D
The priority intervention for a client who is pancytopenic while receiving BMT is to ensure
that a protective isolation environment is maintained (D). After high dose chemotherapy with
or without irradiation, the client remains immunosuppressed during rescue of the
hematopoietic system and is highly susceptible to bacterial, fungal, and viral infections.
Although (A, B, and C) are vital components of the treatment regimen, basic environmental
precautions are critical in preventing exposure to organisms, with resulting infection.
27. ANS: B
The client's hemodynamic pressures indicate severe volume depletion secondary to heat
exhaustion or heat stroke, so the client's IV fluids should be increased to assist in correcting
the volume deficit (B). (A, C, and D) are not useful in correcting the client's hypovolemic state,
and may not be necessary in treating the client's condition.
28. ANS: A
Nausea, tremors, and lethargy are common discomforts associated with the first trimester of
pregnancy. However, this client has Type 1 diabetes, so she should be assessed for
hypoglycemia (A) because insulin needs often decrease in the first trimester. (B) should be
assessed to determine the control of the client's diabetes for the last 3 to 4 months and the
urine assessed for ketones (C), but the most immediate need is to assess for hypoglycemia. If
the client is hypoglycemic, a complex carbohydrate such as graham crackers and peanut
butter should be provided, rather than a protein snack (D).
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29. ANS: B
Placing the client in a Trendelenburg position (C) helps to relieve the pressure of the
presenting part on the cord. The nurse should try to remove pressure of the presenting part
on the cord, and this is accomplished by vaginal exam and holding up the presenting part as
much as possible. (A and B) are important actions for the nurse to perform, but do not have
the priority of placing the client in Trendelenburg position. (D) is not indicated in this
situation.
30. ANS: A
Weighing the child daily (A), or more often, is the best intervention for detecting fluid
retention. (B) should be implemented, but provides a less accurate measure of fluid retention
than (A). (C) is not a good evaluator of fluid retention, but could be used to determine an
obstruction. (D) is an appropriate and necessary intervention for a child with nephrotic
syndrome, but it is used to obtain I&O, and is not an accurate determination of weight gain,
which reflects fluid retention.
31. ANS: D
Children with RSV should not expose other infants (D) to the virus. RSV is the most prevalent
respiratory pathogen found in infancy and early childhood, is an especially contagious virus
because it can live on surfaces outside the body for hours, and is easily passed from person to
person without the need for direct oral contact. (A) does not ensure that the virus is not be
passed to other children and it is impossible to keep a mask on an infant. (B) is incorrect. The
child is still contagious. Even though RSV peaks at 2- to 6- months of age, older infants and
toddlers are susceptible (C).
32. ANS: A
Therapeutic serum levels of antibiotics should be maintained to treat infections such as
urosepsis. The Zosyn should be administered first (A) because Vancomycin must be infused
over at least 90 minutes and if administered first would delay the administration of the Zosyn
by one and one-half hours (B). No ill effects will result from a short delay in the
administration of the Protonix (C) or Lovenox (D).
33. ANS: D
The nurse must monitor the site frequently (D). Extravasation occurs when a vesicant such as
chemotherapy infiltrates the tissue surrounding the intravenous site. To decrease this risk, the
nurse must monitor the intravenous site frequently. (A, B, and C) will not decrease the risk of
extravasation.
34. ANS: B
The client is exhibiting classic signs of an enlarged prostate gland, which restricts urine flow,
and needs further evaluation for diagnosis. This can be done by digital rectal exam (B), so the
nurse should encourage the client to schedule this evaluation. (A, C, and D) are not warranted
based on the client's symptoms.
35. ANS: C
(C) is indicative of increased intracranial pressure (ICP) that is expanding suture lines and
fontanel tension. Normal capillary glucose for a neonate ranges between 40- 80 mg/dl (A). (B)
is at the upper limits of an average gestational age neonate, and the frontal occipital
circumference should be compared with other measurements for the SGA neonate when
reporting the finding. (D) is consistent with increased ICP and may also be seen in congenital
or chromosomal defects that alter vocal cord structure, and should be reported, but (C) is the
most critical finding to report.
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36. ANS: D
Clients undergoing chemotherapy (D) are at particular risk for neutropenia. The healthcare
provider must be notified of the downward trend and precautions must be taken. Clients with
neutropenia (an absolute count of neutrophils less than 2,000) are prone to infections and those
with agranulocytosis (an absolute count less than 500) may have a rapid progression to fatal
sepsis. (A) is currently being treated with the transfusion. (B) often experiences elevated
glucose levels, and sliding scale coverage does not usually occur until the level reaches 200
mg/dl. (C) is an expected finding with hepatitis, which is why the client is jaundiced.
37. ANS: B
A score of ten (B) on the Braden risk assessment scale indicates that the client should be
turned frequently. This scale is a reliable tool used to measure the client's risk for the
development of pressure sores. Scores range from 6 to 23, with the lowest score indicating the
highest risk for pressure sore development. (A) indicates that the client's feet may need to be
elevated, which can be accomplished regardless of the turning schedule. (C and D) indicate
that turning will be beneficial, but these are less specific than (B) with regard to the need for
frequent turning.
38. ANS: D
Response to particular NSAIDs is highly individual (D), so switching to another NSAID may
provide better pain relief. There is no indication of (A). Drug effects are immediate (C).
Recommended doses (B) for adults are 250 to 500 mg twice a day. If the dosage is increased it
is not done by increasing dose frequency.
39. ANS: C
The state's Bureau of Vital Statistics (C) tracks demographic data, including infant death
rates. (A) provides centralized data regarding specific diseases, usually a compilation of
statistical data on cancer and heart disease. A state's Department of Health is not required to
compile infant death rate statistics (B). Census takers do not record vital statistics such as
infant death rates (D).
40. ANS: B
Clients with edema require a neurovascular assessment distal to the problem area (B), not
proximal (C). (A and D) may reveal abnormalities, but are not a priority for the presenting
complaint.
41. ANS: D
Clients who experience high levels of anxiety should be instructed to limit intake of caffeine
and sugar (D) because both are central nervous system (CNS) stimulants. (A) is a symptom of
anxiety and should not be encouraged. (B) is essentially arguing with the client. Alcohol (C)
should not be used for treating anxiety.
42. ANS: C
Puerperal bradycardia (C) is a normal finding in the early postpartum period due to the vast
vasomotor changes occurring in the maternal vascular bed. (A) would not be likely nor
normal for a primiparous client. (B) is excessive lochial flow and is a sign of hemorrhage (one
saturated pad/hour is normal). (D) may indicate thrombus development.
43. ANS: B
The best response is that the medication will help the client to think more clearly (B).
Ultimately, because of improved thinking, the antipsychotic medication is likely to also assist
the client with (A, C, and D).
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44. ANS: D
A C-5 injury can result in edema ascending the spinal cord, which can result in the absence of
breathing, so altered respiratory status should be reported immediately (D). (A and B) are
expected findings in a client with a C-5 spinal cord injury. (C) is within normal limits and
does not require intervention by the nurse.
45. ANS: D
Beractant (D), a lung surfactant, should first be given 15 minutes to 8 hours after birth. RDS
(respiratory distress syndrome) results primarily from immature lungs and the lack of
surfactant (a surface-active lipoprotein mixture that coats the alveoli and prevents their
collapse at the end of respiration). (A and B) would be indicated if sepsis was suspected, but
are not specific for the premature infant. The infant's heart rate is within normal limits, so
(C) would not be indicated.
46. ANS: A
An OB nurse is usually experienced in caring for abdominal surgical wounds (cesarean
sections) and IV infusions, so the adult who had a colon resection would be the best choice (A).
The nurse should not knowingly be exposed to infectious organisms (B) since OB is considered
a "clean area," and the nurse will be returning to work on the OB unit. Ordinarily, OB nurses
are not experienced in assessing and managing care for stroke victims (C) or clients who are in
traction (D).
47. ANS: C
The nurse should prepare the client for a non-stress test (NST), which consists of fetal
monitoring to evaluate fetal heart rate acceleration in response to fetal movements, and
ultrasonography, which measures fetal breathing movements, gross body movements, and
amniotic fluid volume. (A and B) are invasive procedures that require intrauterine sample
collection. (D) measures the fetus's ability to tolerate the stress of labor by simulating uterine
contractions and evaluating for late decelerations, a non-reassuring sign. The most
non-invasive testing should be done first.
48. ANS: C
Any stimulus (sound) can be perceived as a threat and the client cannot deal with excess
stimuli when agitated, so decreasing the volume on the TV may help to reduce the aggression
by reducing external stimuli. (A) is manipulative and cannot be implemented. Extinction
(ignoring the behavior) (B) is not indicated since the client is a danger to self or others, and
safety is a priority. (D) could incite more anger and the client should be removed from the
area to help ensure safety.
49. ANS: D
Silence (D) offers the client a moment for reflection and allows the nurse to demonstrate
respect for the client. Silence does not indicate (A or B), but rather feelings related to the loss.
Silence alone does not signify sadness (C).
50. ANS: B
The charge nurse should review the delivery record to determine if the client received epidural
anesthesia because a spinal headache is a complication that occurs in approximately 2% of
those who receive epidural anesthesia (B). The healthcare provider should be notified (A)
after additional information is obtained regarding labor anesthesia. There is no reason to
suspect that the UAP obtained inaccurate vital signs (C). (D) might be obtained to assess for
excessive bleeding, but the assessment findings do not indicate the possibility of hemorrhage.
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51. ANS: C
(C) will help raise intrapleural pressure which allows emptying of any accumulation in the
pleural space and helps the lung reexpand. Range of motion exercises (A) should be done on
the affected side to help prevent ankylosis of the shoulder and assist in lessening pain and
discomfort. There should be fluctuation of the water level (B) because this shows there is
communication between the pleural cavity and drainage bottle. The Pleuravac® should be
kept below chest level (D) to prevent backflow of fluid into the pleural space.
52. ANS: A
Following surgical repair of an abdominal aortic aneurysm, an N/G tube is needed to
decompress the stomach, and the pedal and posterior tibial pulses need to be assessed
frequently to ensure that the graft is patent (A). Clients are usually encouraged to be out of
bed on the first postoperative day and radial pulses are in the unaffected upper extremities
(B). (C) is contraindicated. An abdominal dressing would be in place rather than a right flank
dressing, and the client would not have a suprapubic catheter (D).
53. ANS: B
When using an incentive spirometer, the client should exhale fully, then place the mouthpiece
in the mouth, and breathe in deeply and slowly over 3 to 5 seconds (B) to fully expand the
lungs by using inspiratory muscles. (A) forces air out of the lungs, rather than increasing the
inspiratory reserve volume, which hyper-inflates the alveoli to prevent atelectasis in the
postoperative period. IS exercises should be done every two hours (D) while the client is
awake during postoperative convalescence. (C) is used to measure tidal volume.
54. ANS: B
Because the client would not be able to show that the nurse's actions resulted in injury, she
would not be able to prove that the nurse was guilty of malpractice (B). For this reason, the
nurse is not guilty of negligence (A). The Good Samaritan Act (C) does not protect nurses who
have established a nurse-client relationship as a function of their job duties. The
administration of the morphine sulfate falls within the scope of registered nurse practice in all
states, so (D) is not necessary.
55. ANS: B
(B) represents the most acute problem, since increasing pain associated with compartment
syndrome may indicate that additional swelling is compromising circulation and nerve
function. (A, C, and D) are less acute problems, since no compromise of circulation is
involved.
56. ANS: B
Only healthcare providers who need to see a client's record to provide care for that client
should have access to such records. The transporter does not have need of the client's record
to provide the care for which he/she has been charged (B). General medical discussions are
always allowed (A). Staff may choose to share appropriate personal information with the
client (C). It is not the charge nurse's role to correct visitor behavior (D).
57. ANS: C
The client should receive preprocedure sedation before leaving the nursing unit (C).
Bronchoscopy involves insertion of a scope into the trachea via the nose or mouth, so (A or B)
are not needed. Supplemental oxygen is generally administered during, but not prior to, the
procedure (D).
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58. ANS: A
Exercising in a swimming pool (A) allows freedom of movement with minimum gravitational
pull and thereby less discomfort. Physical therapy for clients with JRA is directed toward
specific joints and focuses on strengthening muscles, mobilizing restricted joints, and
preventing or correcting deformities. Splinting and positioning of joints helps to minimize
pain, prevents or reduces flexion deformities, and is recommended during periods of rest (B).
To strengthen and mobilize towards maximizing independence, the adolescent should engage
in active (not passive) range of motion exercises (C). (D) may be a more painful
weight-bearing activity and the adolescent's previous level of activities should be considered.
59. ANS: C
Presbycusis (C) is the term for changes in auditory acuity related to age. He is probably losing
his hearing. (A) is exhibited by an acute confusion and no data have been provided to suggest
that this client is confused. (B) is a visual decline in the ability to focus on fine detail which
occurs after the age of 40. (D) is a decline in mental functioning as seen in Alzheimer's disease.
60. ANS: B
Antitussives suppress the cough reflex by acting on the cough control center in the medulla
(B). Antihistamines are prescribed for watery nasal discharge (A) secondary to allergic
rhinitis. A side effect of antihistamines is drowsiness (C), not antitussives. Expectorants (D)
are prescribed to help remove secretions from the lungs.
61. ANS: A
The client who is exhibiting paranoid behavior (A) has a high risk of harming herself or her
children, so the nurse should plan to visit this client first. (B) is not in immediate danger. (C)
is not a high priority. Although (D) may be experiencing depression, she does not have the
priority of a client with paranoid ideation who is having hallucinations about her children's
safety.
62. ANS: A
During cocaine withdrawal, the nurse should expect the client to experience cravings (A) and
a pattern of withdrawal symptoms similar to amphetamine use. (B, C, and D) are signs and
symptoms of a person who is high on cocaine rather than one who is experiencing withdrawal.
63. ANS: B
The nurse should instruct the UAP to pad the side rails with soft blankets (B) because the use
of pillows (A) could result in suffocation. The nurse can delegate padding the side rails to the
UAP (C). A side-lying position (D) may help prevent aspiration during a seizure, but turning
the client is not the priority when implementing seizure precautions.
64. ANS: A
The most important intervention is the initiation of IV fluids (A) because hydration promotes
hemodilution and RBC circulation. (B, C, and D) are also important interventions that should
be implemented by the nurse, but after initiating administration of the IV fluids.
65. ANS: C
Trying to scratch the skin under the cast (C) may cause a break in the skin and result in the
formation of a skin ulcer. Cool air from a hair dryer may alleviate an itch. The affected leg
should be elevated to help decrease edema (A). Ice bags or cold application devices should be
placed on each side of the cast to help decrease edema and pain (B). "Hot spots" (D), or warm
spots on the cast, may indicate infection and should be reported to the healthcare provider
immediately.
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66. ANS: A
Sulfamylon penetrates thick eschar and is excellent for treating electrical burns, but causes
pain that lasts about 30 to 40 minutes after being applied, so the nurse should premedicate the
client for pain (A). (B and C) should be implemented after premedicating the client. ABGs
(D) should be evaluated after treatment because this medication can cause metabolic acidosis,
but it will do no good to assess the client's ABGs prior to the first application.
67. ANS: C
Primary prevention is providing health teaching to prevent disease, so an exercise class (C)
may help prevent heart disease, which is prevalent in the Hispanic population. (A) is tertiary
prevention. (B and D) are examples of secondary prevention.
68. ANS: C
Following an infusion of 2 units of RBCs (C), fluid volume in the vasculature increases, which
increases cardiac preload, thus increasing cardiac output, which is reflected in an increased
blood pressure. Administering (A), a loop diuretic, or (B), an alpha adrenergic blocking agent,
causes a lowering of the blood pressure. (D), an immunosuppressant, has no direct effect on
the blood pressure.
69. ANS: B
If the arm is paralyzed, subluxation at the shoulder can occur from overstretching of the joint
capsule and musculature by the force of gravity. This can be prevented by positioning and
supporting the affected arm (B). The nurse should never lift the client by the flaccid shoulder
or pull on the affected arm or shoulder (A). (C) would be ineffective against pain. To prevent
contractures, passive range of motion exercises should be performed supporting the arm
proximal to the joint being moved (D).
70. ANS: C
Comparing the MAR to the original prescription in the chart for accuracy ensures that the
prescription was entered correctly (C). ( A, B, and D) are all safety measures the nurse should
take when administering medications, but these interventions do not ensure the medication
was transcribed accurately.
71. ANS: B
Stimulation of the rooting reflex (B) is effective in helping the infant grasp the nipple for
breastfeeding. (A) may frustrate a first-time new mother. (C) does not assist the infant to
open its mouth to grasp the nipple. (D) is not necessary prior to giving the infant to the
mother--it can be evaluated while helping the infant to grasp the nipple.
72. ANS: B
Milk products increase gastric acid production and should be avoided, especially at night (B).
The benefit of the tryptophan is outweighed by the harmful effect of milk when drinking it
before bedtime, for the client with GERD (A). (C), along with coffee and peppermint,
predispose the client to reflux. (D) is not useful in the management of GERD.
73. ANS: C
Glucose levels may rise as a result of hepatic glucose production even if the client is NPO, so
the insulin dosage needs to be changed (C) by either omitting the morning dose or
administering regular insulin. (A) may cause the client to experience hypoglycemia. (B) may
result in hyperglycemia. (D) does not fully address the problem, so adjusting the insulin dose
is the better solution.
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74. ANS: B
The best food sources of dietary folate include whole grain breads and cereals (B). Other
foods high in folate are fresh green leafy vegetables, liver, and peanuts. (A, C, and D) are not
the best sources of folic acid, although (C and D) are good sources of protein and vitamin D.
75. ANS: B
The client's hemodynamic readings indicate severe circulatory blood loss, and rapid
replacement of RBCs and fluids is needed (B) to correct the hypovolemia. Vasopressors (A
and C) are not effective in improving the client's hemodynamic status until volume is restored.
Based on the data presented, (D) is not indicated at this time.
76. ANS: B
In emergency situations, if it is impossible to obtain consent from the client or an authorized
person, the procedure required to save the client's life may be undertaken without liability for
failure to obtain consent (B). In such cases, the law assumes that the client would wish to be
treated, so (A) is not needed. A friend (C) cannot sign the informed consent. (D) constitutes
failure to act, in this case by withholding a life-saving treatment until a family member can be
located.
77. ANS: A
A spica cast is used to immobilize the hip and knee. A set of cloth hand puppets (A) provides
an activity that promotes creativity while maintaining safety. (B) has small parts that could be
inserted into the cast, which may result in cellulitis. (C) is too noisy and appropriate for a
younger child, whereas (D) would entertain a school-aged child.
78. ANS: B
When foreign body airway obstruction is suspected in a gravid woman, the nurse should
modify the Heimlich maneuver by applying chest thrusts (B). If the client is in cardiac or
respiratory arrest then the nurse should have someone call 911 and begin CPR (A) with the
appropriate modification for pregnancy (D). Using (C) is not recommended during pregnancy
due to positional changes of internal organs such as the liver.
79. ANS: C
Removing wet blankets and linens from the isolette (C) would prevent further heat loss from
radiation. To assess the infant, the isolette door should remain closed (A) to prevent heat loss.
(B and D) are given within 2 hours of birth.
80. ANS: A
The nurse must respect the client's refusal of treatment and also develop a plan to ensure that
the client receives the needed medication. Therefore, the nurse should reschedule (A) the
medication for times that are acceptable to the client. The client's refusal is based on cultural
values, rather than lack of knowledge, so (B) will not resolve the problem. While the nurse
may need to notify the healthcare provider of the change in the dosage schedule (C), this action
will not resolve the problem as effectively as (A). The nurse cannot prescribe a change in
medication route (D).
81. ANS: B
A large percentage of clients who experience chronic pain become clinically depressed, so it is
essential that the nurse question the client about feelings of depression (B). Tremors (A) are
not commonly associated with chronic pain. Clients with chronic pain are more likely to
experience fatigue than (C). (D) may be experienced if the client is receiving certain
analgesics, but gastric distress is not as typically associated with chronic pain as is depression.
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82. ANS: B
Nubain is a strong analgesic with adverse CNS effects that include sedation, confusion, and
respiratory depression (B). Nubain does not result in (A, C, or D).
83. ANS: B
With ESRD, the renal parenchyma does not produce erythropoietin, resulting in chronic
anemia. Epogen is prescribed to attain and maintain a hematocrit of 30% to 36% (B), which
should increase within 2 weeks of treatment with these drugs. The client's despondent affect
indicates the need for an assessment for depression. (A) lists indices to assess immunological
status. (C) is a clinical parameter that may respond to the therapeutic action of Epogen, but
the lab values provide more accurate clinical markers after 2+ weeks of treatment. (D) lists
electrolytes that should be monitored in ESRD and could influence the client's affect, but do
not respond to this BRM.
84. ANS: A
Since the most common source of E. coli in the body is from the rectal area, males need to
remember when having sexual contact to avoid contacting the rectal area (A) of their partner.
(B) is incorrect. It is not generally associated with prostate problems (C). The condition is
more prevalent in older men who have recently had prostate surgery. (D) is rarely necessary.
85. ANS: C
The oral fluid intake (C) should be restricted. The kidney's sodium regulation mechanisms
keep the serum sodium level stable (normal is 134 to 145 mEq/L). A serum sodium level of 128
mEq/L indicates hyponatremia, usually associated with an excess fluid level, evidenced by neck
vein distention and lung crackles. The client needs a fluid restriction (C) rather than an
increased intake of sodium (A and B), which may further increase the fluid retention.
Diuretics help the client excrete the excess fluid, which is a desirable effect (D).
86. ANS: C
The client's clothes are vital pieces of forensic evidence that reveal bullet entrance, exit, range
of fire, gun soot, as well as blood DNA, so saturated clothing should be placed in a paper bag,
which allows air to dry the blood and preserves DNA evidence. The chain of custody should
be maintained (A) until the nurse gives the evidence (clothing) to a law enforcement officer.
The clothes should be folded, not rolled (B), to preserve gun soot and other markings that
define the bullet entry site. A plastic bag (D) contributes to mold formation, which degrades
DNA as time lapses between transport, storage, and forensic analysis.
87. ANS: A
A critical pathway (A) is an interdisciplinary plan that includes expected outcomes across a
timeline, and is a useful resource in responding to the client. (B and C) are resources related
to reimbursement. (D) describes general responsibilities for which the nurse is accountable.
88. ANS: D
Safety is the priority nursing problem because clients with dementia are not cognitively aware
of potential dangers (D). (A, B, and C) are also indicated for this client, but they are not
priorities over safety.
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89. ANS: D
(D) includes the earliest signs and symptoms of shock. Decreased tissue oxygenation in early
shock first affects the brain, which is dependent on a high concentration of oxygen for
optimum functioning. The earliest signs of shock include mental status changes accompanied
by subtle cardiovascular compensatory mechanisms, including tachycardia, which increases
blood flow to the organs, and reduces volume excretion through the kidneys, thereby
conserving the body's circulatory volume. (A, B, and C) do not describe early symptoms of
shock, although several of these symptoms occur in later stages of shock.
90. ANS: C
Before the thermometer is placed under the arm, a sheath should be used to cover and protect
the thermometer (C). (A) is of little use when preparing to assess an axillary temperature, and
(B) should be done prior to an oral temperature. (D) is necessary when obtaining a blood
pressure measurement, but not a temperature reading.
91. ANS: B
Residual urine is the urine left in the bladder after a client voids, so assessment for residual
urine should be done immediately after a client voids (B). (A, C, and D) would not be the
appropriate time to measure residual urine.
92. ANS: D
A prolonged ulceration (D) is indicative of cancer and should be investigated further. A
mucosal ulceration of short standing (A) should be watched for evidence of healing. (B) is an
expected finding and (C) is an expected variation.
93. ANS: A
The most prominent finding in COPD is increasing dyspnea (A). (B) would not be a
respiratory outcome, but might be a later manifestation. If breath sounds are diminished as a
result of COPD, it would usually be a bilateral, not unilateral (C) problem. (D) is a sign of
right-side heart failure.
94. ANS: D
African-Americans are more prone to lactose intolerance, and further assessment is needed to
determine if the infant in (D) should be switched to a soy-based formula. A common treatment
for fevers and infections among Asians is cupping, which leaves red marks on the back and
does not harm the child (A). Hispanics tend to be present-oriented, and being late for an
appointment is not a significant factor to them (B). Native-Americans consider direct eye
contact distasteful or disrespectful (C).
95. ANS: C
The client is exhibiting symptoms of fluid volume overload because 200 ml of the 250 ml unit
of packed red blood cells infused in 30 minutes, so the best action is to decrease the flow rate of
the transfusion (C). (A) is not necessary since there are no signs of a transfusion reaction,
either hemolytic or allergic. (B) will contribute to the fluid overload. Though shortness of
breath may be temporarily abated with (D), the priority intervention at this time is to slow the
rate of infusion to prevent the fluid volume overload from worsening.
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96. ANS: B
The nurse should decrease the rate of the IV solution to a keep-open rate to avoid further fluid
volume overload (B) while awaiting a change in prescription from the healthcare provider.
The client has received a large amount of fluid in a short period of time and is exhibiting signs
of fluid volume excess. An IV diuretic or other emergency medication may be prescribed, so
the IV should not be removed (A). (C) will worsen the fluid volume excess already exhibited
by the client. Changing the IV solution (D) to a hypotonic solution is likely to worsen the fluid
volume excess.
97. ANS: B
The client needs to contact her HMO first (B) to see if a transplant is a covered treatment
option. If the transplant is not covered by the HMO, the client may be able to seek recourse as
explained in the Patient's Bill of Rights published by the American Hospital Association. (A,
C, and D) describe actions that are premature at this time.
98. ANS: A
It is important to immediately stop the potential harm to the client by removing the water and
speaking to the UAP (A). (B and C) do not prevent a reoccurrence. The client may not be able
to understand pathophysiologic rationale (D). It is the nurse's responsibility to safeguard the
client and ensure that the unlicensed staff working with the nurse provide safe care.
99. ANS: A
Mobilization and ambulation increase the utilization of oxygen, so the nurse should assess the
client's respiratory rate (A), which is useful information about the client's tolerance for
activity. (B, C, and D) are less likely to provide data related to exercise tolerance.
100. ANS: B
Physiologic stability must be established first (B), and assessing the client's current weight,
vital signs and electrolyte status provides baseline information. (A, C, and D) are
interventions that should be implemented after assessing the client's current physiological
state.
101. ANS: C
Asymmetrical chest wall excursion (D) indicates a flail chest which may lead to decreased
cardiac output due to a mediastinal shift. (A, B, and C) would be expected findings.
102. ANS: C
The client is alert, normotensive, and is demonstrating a regular, narrow-QRS, sinus
tachycardia, so adenosine (C) is the drug of choice for a stable tachycardia requiring
medical management. (A) is indicated in wide-QRS ventricular tachycardia, such as torsades
de pointes. Anticoagulation (B) is indicated in irregular tachydysrhythmias, such as atrial
fibrillation. (D) is indicated if the client becomes unstable or is unresponsive to adenosine or
second-line medications.
103. ANS: B
Initiating short, frequent contacts (B) will promote trust and help establish rapport. When a client is
delusional, offering (A and C) may cause the client to become defensive. If the client is very
delusional, it is doubtful that she will want her belongings kept at the nurse's desk (D).
104. ANS: C
Kayexalate (C) is an ion exchange resin which removes potassium through the feces (normal
potassium is 3.5 to 5.5 mEq/L). (A) is prescribed for a client diagnosed with cystitis. (B) is
used to treat anemia in clients with chronic renal failure. (D) is used to prevent rejection in a
client with a kidney transplant.
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105. ANS: B
An Occupational Therapist can train the client to use adaptive devices to maintain self-care in
feeding (B). Feeding the client is demeaning to the client, and should not be the first action
taken (A). (C and D) will not be useful for the client's problem which requires help with fine
motor skills.
106. ANS: D
Although positioning an infant on the back while sleeping significantly reduces the incidence
of sudden infant-death syndrome (SIDS), a certain amount of tummy time while the infant is
awake, active (D) and being observed is recommended for upper body development and to
help prevent positional plagiocephaly (flattening of the occiput).
(A, B and C) are not safe positions for a one-month-old infant.
107. ANS: C
The statement "Tell me what concerns you have" (C) is an open-ended statement that provides
an opportunity for the client to talk and express anxieties and concerns. (A) provides
generalized reassurance without first determining why the client feels anxious. (B) is a closed
statement that does not encourage further verbalization by the client. (D) assumes that the
client's anxiety is caused by fear of postoperative pain, which may not be accurate.
108. ANS: C
Centers for Disease Control (CDC) guidelines for interpreting Mantoux test results state that the
induration (raised area) should be palpated and inspected, and that the diameter of the induration
should be measured at the widest point (C). The site may or may not have erythema, or reddening of
the skin, but erythema should not be measured. (A) does not necessarily indicate the presence of
active disease; more than 90% of those with a positive reaction do not develop clinical TB. The test is
read 48 to 72 hours after injection (B). 0 to 4 mm is not considered to be a significant reaction (D). 5
mm or greater may be significant, and greater than 10 mm is usually considered to be significant.
109. ANS: C
The best way to establish communication with a hearing impaired person is to stand close to
the individual to attract their attention before speaking (C). (A) is more time consuming to
communicate and does not encourage lip reading, which enhances verbal interaction. (B) can
add emotions to the message, but they can also result in misinterpretation of the
communication. (D) is best used for clients with speech and language disorders, such as
aphasia.
110. ANS: D
Nephrotoxic medications can cause damage to the kidneys, reducing glomerular filtration
rates. The client with diminished creatinine clearance (D) already has diminished kidney
function, so a reduction in dose of a nephrotoxic medication is likely. (A, B, and C) do not
reflect problems with kidney function that require a decrease in the dosage of a nephrotoxic
medication.
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111. ANS: A
Variance in CVP readings (normal is 2 to 6 mmHg) is influenced by client position. When
using the PA catheter for CVP readings, the transducer should be zeroed to the phlebostasis
axis whenever there is a change in the relationship of the client to the transducer or lumen
opening. The nurse should first verify the zero-reference point for both readings (A), then
assess for fluid overload by reviewing recent intake, output, and other cardiac hemodynamic
measurements (B). Before reassessing the client, the nurse should evaluate the client position
to provide consistent hemodynamic measurements (C). After verifying the client's position (or
zero-reference point) of both readings, the healthcare provider should be notified if the
reading is reliable (D).
112. ANS: B
Once urine is observed, the catheter should be inserted another inch (B), to ensure that the
balloon will be inflated in the bladder, rather than the urethra (C). (A) is done at the
completion of the procedure. (D) is most beneficial during the initial insertion of the catheter.
113. ANS: C
This client should be returned to bed and then assessed for possible deep vein thrombosis
(DVT) (C). The client is at high risk for DVT and is reporting calf pain, a symptom of DVT.
(A) is contraindicated. The client should immediately be placed on bedrest. Once the client is
in bed, (B) may be used as part of the assessment. (D) is not cautious enough and does not
acknowledge the need for further assessment of the client's symptoms.
114. ANS: A
Elevating the head of the bed decreases edema and promotes venous drainage (A). PCAs
usually deliver opioid analgesics, which are generally contraindicated in neurosurgery (B).
The IV rate in (C) is too fast for a 10-year old child with this type of surgery. Usually 30 to 50
ml/hr is prescribed. The nurse can assess the dressing for saturation without removing it (D).
115. ANS: C
Lanoxin slows and strengthens the heartbeat, thereby improving cardiac output and kidney
perfusion (C). Digoxin slows (A) the heart rate. Both (B and D) are increased.
116. ANS: A
Agranulocytosis (A) refers to a significant lack of granulocytes, or white blood cells, which are
instrumental in fighting infections. (B), a lack of platelets, would place the client at risk for
bleeding problems. (C), a lack of red blood cells, can lead to fatigue and activity intolerance.
(D), an excess of red blood cells, can cause problems related to hyperviscosity of the blood.
117. ANS: A
The nurse should first assess the client for clinical signs and symptoms that would indicate that
the 85% rate was accurate (shortness of breath, cyanosis, etc.). Although a valuable
monitoring tool, pulse oximeters are very sensitive to changes in the probe's position, and to
position changes of the extremity where the probe is located. If such signs do not exist,
adjusting the probe is likely to give an accurate, higher reading (A). After further assessment
is completed, (B and C) may be indicated. (D) does not address the problem.
118. ANS: B
Analysis of cerebrospinal fluid (CSF) is the best diagnostic test for meningitis. CSF is obtained
via lumbar puncture (B), unless contraindicated because of increased intracranial pressure.
(A) is not useful in diagnosing meningitis. (C) may be useful to assess the degree of neurologic
damage caused by the meningitis, but not diagnosis. Skull x-rays may be performed to assess
the cause of the meningitis, but (D) would not provide useful information in this diagnosis.
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119. ANS: A
Resuscitative efforts should have already begun on an infant who has an Apgar score of 3 at
one minute, and it is most important that these efforts continue (A). (B, C, and D) are
important, but do not have the priority of (A).
120. ANS: A
Enalapril (Vasotec), an ACE inhibitor, is used to treat hypertension and may cause orthostatic
hypotension and dizziness following administration. Following administration of the initial
dose of an ACE inhibitor, it is important for the nurse to assist the client with ambulation (A)
to assess for these responses while helping to ensure client safety. (B, C, and D) may be
indicated based on the client's condition, but are of less priority immediately following
administration of the initial dose of Vasotec than is (A).
121. ANS: D
(D) requires the least amount of teaching and evaluating, so the charge nurse should assign
this client to the new graduate RN. The charge nurse should assign the clients that require
more teaching and evaluating to the more experienced nurses (A, B, and C) until the new
graduate RN has more experience.
122. ANS: C
A decreased creatinine clearance (C) is an indication of renal impairment. The nurse should
contact the healthcare provider with this data, so that the prescribed dose can be reduced. A
reduced dose of many medications, including Zosyn, is needed for clients with impaired renal
function, since excretion of the drug will be altered. Zosyn is a broad-spectrum penicillin,
effective against gram positive bacteria (A). (B) is an expected finding in infection. Zosyn
dosage does not need to be altered due to hypokalemia (D).
123. ANS: B
The symptoms of Parkinson's disease are caused by insufficient dopamine to maintain normal
muscle function (B). Hand tremors, while typical of the disease, are not the result of (A or D).
(C) describes the pathology of multiple sclerosis
124. ANS: D
(D) assesses for impaired respiratory functioning (signs of pneumonia), which are the most
important assessment data for the nurse to obtain. (A, B, and C) provide worthwhile
assessment findings, but these do not have the priority of (D).
125. ANS: B
Generalized pain and insufficient sleep (B) are the typical symptoms of fibromyalgia. (A, C,
and D) are not specifically associated with fibromyalgia.
126. ANS: B
Anxiety and restlessness are affective effects of sensory deprivation, which may occur when a
client is placed in isolation with minimal stimuli. Encouraging family members to visit
frequently (B) can reduce these effects of isolation. Droplet precautions require continued use
of a private room, so (A) cannot be implemented. (C) is likely to worsen the effects of sensory
deprivation and restrict needed care. Restraints (D) are not indicated for anxiety and
restlessness.
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127. ANS: A
Untreated PCP will eventually cause significant pulmonary impairment and ultimately
respiratory failure. Some clients have a dramatic onset and fulminating course involving
severe hypoxemia, cyanosis, tachypnea and altered mental status (D). Respiratory failure can
develop within 2 to 3 days of initial symptoms. (A) occurs in wasting syndrome, and (B) in
oral candidacies infection. PCP is characterized by a dry cough, and if crackles are present,
they are dry; ABGs may be slightly abnormal in early stages and quite abnormal in later
stages (C).
128. ANS: A
Immunization against common childhood illnesses, including pneumococcal and influenza
vaccines, is recommended for all children exposed to and infected with HIV, so the nurse
should review the immunization records of the child with HIV (A) to determine what action
should be taken. (B) is not necessary. (C and D) may be a possibility if the child has not had a
DPT immunization or has a low T-cell count.
129. ANS: A
The nurse should refuse to give the medication since it is an overdose and may be the
healthcare provider's attempt to perform euthanasia (A). (B and C) may need to be
performed, but are not the most important action. (D) does not reduce the nurse's
responsibility in refusing to perform an illegal act.
130. ANS: A
The primary treatment of Celiac disease is dietary management (A) involving removal of
gluten from the diet. Relapse occurs as a result of poor dietary control. (B, C and D) are
viable topics, but are not the primary teaching focus at this time.
131. ANS: B
Dehiscence (B), an opening in the wound, places the client at high risk for evisceration of the
abdominal contents, a potentially life-threatening complication. Therefore, further assessment
of this situation has the highest priority. (A) indicates the onset of skin damage, which
requires action but is not of high priority. An infected pressure ulcer (C) requires prompt
attention, but is of less immediacy than (B). Necrotic (D) tissue, which is already dead, does
not require immediate intervention.
132. ANS: A
The nurse should cleanse the wound first (A), and implement (B) next. (C and D) are not
indicated in this situation.
133. ANS: B
The client is exhibiting characteristics of despair (B), consistent with Erikson's final
developmental stage of Integrity vs. Despair, in which the older adult seeks to determine that
one's life has had meaning and purpose. Negative resolution of this stage may result in
withdrawal, crying, and demands for excessive attention. (A) is not defined as a stage by
Erikson. According to Erikson's developmental stages, (C) occurs at infancy, and (D) occurs
at young adulthood.
134. ANS: B
A stoma that is purple in color has a compromised blood supply, and must be treated immediately by
the surgeon (B). (A, C, and D) are normal findings for a client with a sigmoid colostomy.
135. ANS: D
One kilogram of weight gain (2.2 pounds) is equivalent to one liter of fluid volume retention, so
the client has retained three liters (D) of fluid.
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136. ANS: C
The charge nurse should assign the least critical client to the RN that just completed the
internship and the client with chest tubes is the least critical (C) of these four. The more
critically ill clients (A, B, and D) should be assigned to the more experienced nurses because
they have life-threatening conditions and high mortality rates.
137. ANS: C
It is a violation of a client's right to privacy to take their picture without consent, so (C) has the
highest priority. The nurse should also implement (A and B), but these actions do not have the
priority of (C). (D) is important, but it is most important to obtain written consent for the use
of a personal picture.
138. ANS: D
Enoxaparin sodium (Lovenox) should be administered in the abdominal area below or lateral
to the periumbilical region with the client recumbent. The nurse should first observe these
areas for any excessive bruising (D). (A, B, and C) are not recommended for administration of
this medication.
139. ANS: B
Because of the densely packed keratin composition of nails, the best way to eliminate
onychomycosis, a fungal infection, is to take a prescribed systemic antifungal medication (B).
(A, C, and D) will help to strengthen the nail plate, but systemic antifungal medication is the
best measure to use to cure the infection.
140. ANS: A
Regular aerobic exercise reduces menstrual cramping and pain by promoting relaxation and
the release of endorphins (A). (B) is beneficial for older women to promote bone strength, but
will not reduce menstrual discomfort. (C) promotes abdominal tone, and reduces back pain.
(D) is useful for the woman with diminished bladder tone.
141. ANS: C
Excessive warfarin is evaluated by an increase in the client's PT/INR (C). (A) is not essential,
since the blood in the urine is visible. (B) may be useful, but is of less priority than (C). (D)
will provide additional supportive data, but is of less importance than an increase in the
PT/INR.
142. ANS: A
Smoked meats are typically high in sodium, so the client should be instructed to replace the
ham with a low sodium item such as toast and jelly (A). Eggs (B) are not high in sodium.
Daily use of a salt substitute (C) is safe unless the client has hyperkalemia. Herbal tea (D) is
not high in sodium
143. ANS: B
Smoking is a risk factor for the development of pneumonia, so the client should be encouraged
to stop, or at least decrease, smoking (B). (A) decreases the risk for deep vein thrombosis. (C)
may decrease the risk for heart attack or stroke, and (D) is helpful in preventing hypertension.
144. ANS: A
Clients with chronic pain often experience hopelessness (A), which the nurse recognizes by the
client's withdrawal and refusal to make decisions. (B) may become a priority problem if the
client also refuses to participate in self-care measures. There is no indication that the client is
experiencing (C or D).
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145. ANS: A
The provision of care around the urethral opening for a client with an indwelling urinary
catheter is not a sterile procedure, so the nurse should advise the UAP that exam gloves should
be worn for the protection of the UAP, and sterile gloves are not necessary (A). This is a
non-invasive task that can be performed by the UAP (B). The UAP has obtained unnecessary
and expensive sterile gloves, so further instruction is needed (C). A sterile field (D) is not used
to perform catheter care.
146. ANS: B
Administration of IV antibiotics via a subclavian line (B) is a task the nurse is likely to have
performed in an acute care setting, and this activity will assist in building the nurse's
confidence. Admission assessment is a very complex and lengthy process (A), which may
intimidate the new home health care nurse. To maintain continuity of care, the nurse who has
been caring for the client being discharged should complete (C). (D) should be referred to a
hospice nurse, a chaplain, or a social worker.
147. ANS: B
Autonomic dysreflexia is an acute emergency that occurs because of an exaggerated autonomic
response such as a full bladder. The client may have a severe, pounding headache with
paroxysmal hypertension, profuse diaphoresis (mostly forehead), nausea, nasal congestion and
bradycardia (B). (A) are signs/symptoms of spinal shock that occur immediately after spinal
cord injury. (C) are signs/symptoms of pulmonary embolus. (D) are signs/symptoms of
possible urinary tract infection.
148. ANS: A
The highest priority for this client, is risk for injury related to uterine atony (A). A client who
is treated with magnesium sulfate has an increased risk for hemorrhage because magnesium
sulfate is a CNS depressant and muscle relaxant. (B, C, and D) do not have the priority of (A).
149. ANS: A
It is most important for the nurse to determine medication compliance (A) because the client's
lithium level is below the therapeutic range of 0.8 to 1.4 mEq/L. Questioning the client about
(B and C) can occur after determining medication compliance. (D) does not need to be
completed at this time.
150. ANS: A
Spilled solution (A) will allow capillary action to contaminate the sterile field. Sterile gloves
should be applied after pouring the solution (B). The solution cap (C) is not sterile, and
placing in on the sterile field would contaminate the field. (D) does not impact asepsis once the
solution is poured.
151. ANS: C
A prone position (C) will stretch the flexor muscles and help prevent flexion contracture of the
hip. (A) is incorrect because a flexion contracture of the hip may result. (B) will toughen the
stump but will not prevent contractures. The client should be turned from side to side to
prevent flexion contracture, not just to the unaffected side (D).
152. ANS: D
Breaking client confidentiality is a breach of fidelity (D), the ethical principle which relates to
keeping one's word. When a client is admitted to a hospital, an expectation of privacy and
confidentiality is incurred by the client, and assured by the hospital. (A) relates to
truthfulness. (B), while not an ethical principle, relates to ensuring a degree of sameness. (C)
relates to self-determination.
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153. ANS: B
The nurse should initiate the normal saline infusion (B) first to replace intravascular fluid
volume because the client is hypotensive and hyponatremic (normal 135 to 145 mEq/L) due to
heat exposure and diaphoresis. Oliguria should be assessed because it is a compensatory
mechanism used to conserve body fluids that also contributes to hyponatremia, so the nurse
should insert the indwelling catheter (A), but first saline replacement should be initiated. (C
and D) can assist in the definitive evaluation of the tachycardia and syncope, but first fluid and
electrolyte replacement should be initiated.
154. ANS: B
Hypoparathyroidism occurs when the parathyroid glands are accidentally removed during the
thyroidectomy, decreasing calcium levels and resulting in tetany (B). (A) would be indicative
of hyperparathyroidism. (C) is a desired outcome and would indicate that
hypoparathyroidism had not developed. The symptoms described in (D) are not signs of
hypoparathyroidism, but of a tumor of the adrenal medulla (pheochromocytoma).
155. ANS: C
(C) provides the client with correct information (her risk is low), offers praise for her health
maintenance behavior, and does not give false reassurance. (A) gives false
reassurance--although malignant masses typically are not painful, some are. (B) is technically
correct information but does not take into consideration the client's emotional state. (D) is
shaming, does not offer emotional support, and could alarm the client.
156. ANS: D
Clients who experience high levels of anxiety should be instructed to limit intake of caffeine
and sugar (D) because both are central nervous system (CNS) stimulants. (A) is a symptom of
anxiety and should not be encouraged. (B) is essentially arguing with the client. Alcohol (C)
should not be used for treating anxiety.
COMPLETION
157. ANS: 100
158. ANS:
20 ml/hr
176 lb divided by 2.2 lb/ kg = 80 kg.
Begin the infusion at 1,000 units/hour. Calculate using the formula: D/H x Q=
1000 units/hr / 25,000 units x 500 ml = 20 ml/hr
159. ANS:
1.75
Demerol:
100:1 = 75:X
X = 75/100 = 3/4 ml or 0.75 ml
Phenergan:
1 ml = 25 mg
Amount to administer: 0.75 ml of Demerol +1 ml of Phenergan =1.75 ml
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160. ANS:
250
Using the intravenous flow rate formula:
Total volume / time in minutes X drop (gtt) factor = # gtt per minute, then
1000 ml / 240 x 60 gtt/ml = 250 gtt per minute.
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