Nursing Exam Part 1

NURSING EXAM PART 1 1. The nurse is teaching a client about self-examination. The client asks the nurse where masses are most often found. Which response(s) by the nurse are most appropriate? Select all that apply. A. B. C. D. E. In the axlla Beneath the nipple Lower inner quadrant Upper outer quadrant Lower outer quadrant 2. The nurse is assessing a client with herpes zoster. Which characteristic(s) does not the nurse expect to note when assessing the lesions of this infection? Select all that apply. A. B. C. D. E. Clustered skin vesicles A generalized body rash Small blue-white spots with a red base A fiery red edematous rash on the cheeks Grouped vesicles on an erythematous base. 3. A client is scheduled for a craniotomy to remove a brain tumor. To prevent the development of cerebral edema after surgery, the nurse anticipates the use of: A. B. C. D. Steroids Diuretics Anticonvulsants Antihypertensive 4. A nurse driving along the scene of an accident and stops to assist with a deep laceration his hand, a fractured arm and leg, and abdominal pain. The nurse wraps the man’s hand in asoiled cloth and drives him to the nearest hospital. The nurse is: A. B. C. D. Practicing her skills as a nurse Negligent and can be sued for malpractice Practicing under guidelines of the Nurse Practice Act. Protected for these actions, in most states, by Good Samaritan legislation 5. A visitor in the room adjacent to a client asks the nurse what disease the client has. The nurse responds, “I will not discuss my client’s illness. Are you worried about it?” This response is based on the nurse’s knowledge that to discuss a client’s condition with someone not directly involved with the client is an example of: A. Negligence 1/53 B. Breach of confidentiality C. Libel D. Defamation of character 6. When approaching homosexual clients with acquired immunodefiency syndrome (AIDS), it is most important for nurses to: A. B. C. D. Establish a meaningful rapport with clients Having strong sense of their own sexual identity Admit their own feelings or discomfort towards them Become aware of their own attitude towards homosexuality 7.The client has a prescription for a calcium carbonate compound to neutralize stomach acid. The nurse should assess the client for: A. B. C. D. Constipation Hyperphosphatemia Hypomagnesaemia Diarrhea 8. Heparin has been ordered for a client with pulmonary embolis. Which of the following statement, made by the graduate nurse, indicated a lack of knowledge regarding the medication? A. B. C. D. “I will administer the medication 1-2 inches away from the umbilicus.” “I will administer the medication in the abdomen area.” “I will check the PTT before administering the medication.” “I will need to aspirate when I give the Heparin.” 9. The nurse is preparing a client with an axillo-politeal bypass for discharge. The client should be taught to avoid: A. B. C. D. Using a recliner to rest. Resting in supine position Sitting in a straight chair Sleeping in right Sim’s position 10. The nurse has just receive the shift report and is preparing to make rounds. Which client should be seen first? A. B. C. D. The client with a history of a cerebral aneurysm with oxygen saturation rate of 99% The client three days post-coronary artery bypass graft with temperature of 100.3 degree F. The client admitted 1 hour ago with shortness of breath. The client being prepared for discharge following a femoral politeal bypass graft 2/53 11. The nurse is teaching the client regarding use of sodium warfarin. Which statement made by the client would indicate further teaching in required? A. B. C. D. “I will have my blood drawn every month.” “I will assess my skin for a rash.” “I will take aspiring for my headache.” “I will use an electric razor to shave.” 12. If an interpreter is not available when a patient speaks a language different from the nurse’s language, it is appropriate for the nurse to A. B. C. D. Use specific medical terms in the Latin form. Talk slowly so that each word is clearly heard. Repeat important words so that the patient recognize their importance Use simple gestures to demonstrate meaning while talking to the patient. 13. Which action should the nurse take to monitor the effects of an acute stressor on a hospitalized patient (Select all that apply)? A. B. C. D. E. Assess for bradycardia Ask about epihastric pain Observe for increased appetite Check for elevated blood glucose levels Monitor for a decrease in respiratory rate 14. A patient who has fibromyalgia tells the nurse, “My life feels very chaotic and out of my control will not be able to manage if anything else happens.” Which response should the nurse make initially? A. B. C. D. “Regular massages may help reduce muscle pain.” “Guided imagery can be helpful in regaining control.” “Tell me more about how your life has been recently.” “Your previous coping mechanisms can help you now.” 15. The health care provider plans to titrate a patient-controlled analgesia (PCA. Machine to provide pain relief for a patient with acute surgical pain who has never received opoids in the past. Which of the following nursing actions regarding opoid administration are appropriate at this time (select all that apply)? A. B. C. D. E. Assessing for signs that the patient is becoming addicted to the opiod Monitoring for therapeutic and adverse effects of opiod administration Emphasizing that the risk of some opiod side effects increases over time Educating the patient about how analgesics improve postoperative activity levels. Teaching about the need to decrease opiod doses by the second postoperative day 3/53 16. A terminally ill patient is admitted to the hospital. Which action should the nurse include in the initial plan of care? A. B. C. D. Determine the patient’s wishes regarding end of life care Emphasize the importance of addressing any families issues Discuss the normal grief process with the patient and family Encourage the patient to talk about any fears or unresolved issues. 17. A patient’s temperature has been 101 F. (38.3 C. for several days. The patient’s normal caloric intake to meet nutritional needs is about 2000 calories per day. Knowing that the metabolic rate increases 7% for each Fahrenheit degree about 100 degrees in body temperature, calculate the total calories the patient should receive each day__________ 18. On the examination the following question will ask to put in order: A patient who has an infected abdominal wound develops a temperature of 104 degree F. (40 C. All the following interventions are included in the patient’s plan of care. In which order should the nurse perform the following actions? A. B. C. D. Sponge patient with water Administer intravenous antibiotics Perform wet to dry dressing change. Administer acetaminophen (Tylenol) 19. The nurse has administered 3% saline to a patient with hyponatremia. Which one of these assessment data will require the most rapid response by the nurse? A. B. C. D. The patient’s radial pulse is 105 beats/minute There is sediment and blood in the patient’s urine The blood pressure increases from 120/80 to 142/94 There are crackles audible throughout both lung fields 20. The following data are prohibited by the nurse when assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate. Which finding is most important to report to the health care provider immediately? A. The bibasilar breath sounds are decreased. B. The patellar and triceps reflexes are absent C. The patient has been sleeping most of the day. D. The patient reports feeling “sick to my stomach.” 4/53 21. A patient with advanced lung cancer is admitted to the emergency department with urinary retention caused by renal calculi. Which laborarotory values will require the most immediate action by the nurse? A. Arterial blood pH is 7.32. B. Serum calcium is 18 mEq/L. C. Serum potassium is 5.1 mEq/L D. Arterial oxygen saturation is 91% 22. A home care nurse is preparing to visit a client with a diagnosis of Meniere’s disease. The nurse review’s the physician’s orders and expects to note that which of the following dietary measures will be prescribed? A. Low fiber diet with decreased fluids B. Low sodium diet and fluid restriction C. Low carbohydrate diet and elimination of red meats D. Low fat with restriction of citrus fruits 23. A nurse is assigned to care for a client who has just undergone eye surgery. The nurse plans to instruct the client that which of the following activities Is permitted in the postoperative period? A. Reading B. Watching television C. Bending over D. Lifting objects 24. A client has undergone surgery for glaucoma. The nurse provides which discharge instructions to the clients? A. Wound healing usually takes 12 weeks B. Expected the vision will be permanently impaired C. A shield or eye patch should be worn to protect the eye D. The structures are removed after 1 week 25. When the nurse prepares the client or the myringotomy , the best explanation as to the purpose for the procedures is that it will: A. Prevent permanent hearing loss 5/53 B. Provide a pathway for drainage C. Aid in administering medications D. Maintain motion of the ear bones 26. A nurse is reviewing the record of the client with a disorder involving the inner ear. Which of the following would the nurse expect to see documented as an assessment finding in this client? A. Severe hearing loss B. Complaints of severe pain in the affected ear C. Complaints of burning in the ear D. Complaints of tinnitus 27. The nurse cares for a toddler diagnosed with pneumonia caused by Haemophilusinfluenzae. The nurse should follow which of the following transmission based precautions? A. Standard precautions B. Airborne precautions C. Droplet precautions D. Contact precautions 28. The nurse expects the emotional responses of a client with a cerebral vascular accident (CVA. Of the left hemisphere to be MOST influenced by which of the following? A. The client’s ability to understand the illness and treatment B. The client’s perception of the care received during his illness C. The client’s personality and general health prior to the CVA D. The type of lesion that caused the CVA 29. The nurse that which of the following clients are at risk to develop pneumonia? Select all that apply. A. A 16 year old male who has experimented with cigarettes B. A 25 year old female diagnosed with cystic fibrosis C. A 36 year old male diagnosed with Addison’s disease D. A 47 old male diagnosed with hypertension E. A 68 year old with a fracture rib due to an auto accident F. A 79 year old female in Buck’s traction due to a fractured hip. 30. Health teaching for Barbara includes ensuring that she understands that 6/53 A. Proper prophylactic medication can control the incidences of seizures B. Moderate use of alcohol is permitted C. Forcing fluids helps to reduce the incidence of seizures D. The incidence of seizures is related to hyperglycemia 31. to prepare Barbara for EEG, the nurse should explain that A. During the test she will experience small electrical shocks that feel like pin pricks B. The test measures mental status as well as electrical brain waves C. During the hyperventilation portion of the test, she may experience dizziness D. She will be unconscious during the test 32.Situstion: Barbara is a 23 year old woman who lives with her mother, sister and brother in a private residence. She is attending the neurological out-patient clinic for the first name. her health history includes two grand mal seizures/A diagnosis of idiopathic epilepsy has been made. The physician has ordered an electroencephalogram (EEG) and phenytoin sodium (Dilantin), 300 mg/day. While doing a nursing history on Barbara, the nurse should recognize that A. Persons with idiopathic epilepsy have a lower intelligence level B. Grand mal seizures do not cause mental deterioration C. A common characteristics of idiopathic epilepsy is committing acts of violence D. Idiopathic epilepsy is a form of mental illness 33. A client has been hospitalized after an automobile accident. A full leg cast applied while inside the emergency room. The most important reason for the nurse to elevate the casted leg is to: A. Reduce the drying time B. Decrease irritation to the skin C. Improve venous return D. Promote the client’s comfort 34. The nurse is reviewing with a client how to collect a clean catch urine specimen. What is the appropriate sequence to teach the client? A. Clean the meatus, begin vomiting, and then catch the urine stream B. Void a little, clean the meatus, then collect specimen C. Clean the meatus, then urinate into container D. Void continuously and catch some of the urine. 7/53 35 The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing the client? A. Apical pulse rate of 110 and 4 + pitting edema of feet B. Thick white sputum and crackles that clear with cough C. The client sleeping with no pillow and eupnea D. Radial pulse rate of 90 and capillary refill time less than 3 seconds 36. The nurse is assessing the client with congestive heart failure. Which signs and symptoms would indicate that the medical treatment has been effective? A. The client’s peripheral pitting edema has globe from 3+ to 4+ B. The client is able to take the radial pulse accurately C. The client is able to perform activities of daily living without dyspnea D. The client has minimal jugular vein distention 37. The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing diagnosis of “decreased cardiac output related to inability of the heart to pimp effectively” is written. Which short-term goal would be best for the client? The client will: A. Be able to ambulate in the hall by date of discharge B. Have an audible S1 and S2 with no S3 heard be end of shift C. Turn, cough, and deep breather every two (2) hours D. Have a pulse oximeter reading of 98% by say two (2) of care 38. The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which intervention should be included in the plan? Select all that apply. A. Notify health care provider of more than 1 pound a week B. Teach client how to count the radial pulse when taking dixogin, a cardiac glycoside C. Instruct client to remove the saltshaker from the dinner table D. Encourage client to monitor urine output for change in color to become dark E. Discuss the importance of taking the loop diuretic Furosemide at bedtime 39. The nurse is caring diagnosed with myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement? A. Administer morphine via IV B. Administer an aspirin orally 8/53 C. Apply oxygen via nasal cannula D. Place the client in a supine position E. Administer nitroglycerin subcutaneously 40. Which client teaching should the nurse implement for the client diagnosed with coronary artery disease? Select all that apply. A. Encourage a low-fat, low-cholesterol diet B. Instruct client to walk 30 minutes a day C. Decrease the salt intake to 2 grams a day D. Refer to counselor for stress reduction techniques E. Increase fiber in the diet 41. Which signs and symptoms should the nurse assess in any client who has a long term valvular heart disease? Select all that apply. A. Paroxysmal nocturnal dyspnea B. Orthopnea C. Cough D. Pericardial friction rub E. Pulsusparadous 42. The client is in ventricular fibrillation. Which interventions should the nurse implement? Select all that apply. A. Start cardiopulmonary resuscitation B. Prepare to administer the antidyrhtymic adenosine IVP C. Prepare to defibrillate the client D. Bring the crash cart to the bedside E. Prepare to administer the antidysrhythmicamiodacrone IVP 43. The health care provider orders a medication in a dose that us considered toxic. The nurse administers the medication to the client, who later suffers cardiac arrest and dies. What consequence can the nurse expect from this situation? Select all that apply. A. The health care provider can be charged with negligence, being the person who ordered the dose B. As the employing agency, only the hospital can be charged with negligence 9/53 C. The nurse and physician may be terminated from employment to prevent a charge of negligence to the hospital; D. Negligence will not be charged, as this event could happen to any reasonable person E. The nurse can be charged with negligence for administering the toxic dose 45. Which action would the nurse take to maintain medical asepsis when caring for a client with diabetes mellitus on the medical nursing unit who requires irrigation of a leg ulcer and insulin injections? Select all that apply. A. Wash hands before and after client care. B. Wear personal protective equipment during the dressing change C. Recap a needle after administering insulin D. Change the dressing for a diabetic ulcer using sterile globes E. Wipe the rubber stopper on the insulin vial before withdrawing dose 46. Following a liver transplant the client is taking prednisone and other medications to prevent organ rejection. The nurse should instruct the client to make priority to report which manifestation to the heath care provider? A. Moon face B. Diminished pigmentation C. Dysphasia D. bleeding 47. Kevin is a member of the Nursing Research Council of the hospital. His first assignment is to determine the level of patient satisfaction on the care they received from the hospital. He plans to include all adult patients admitted from April to May, with average length of stay of 3-4 days, first admission, and with no complications. Which of the following is an extraneous variable of the study? A. Date of admission B. Length of stay C. Age of patients D. Absence of complications 48. He thinks of an appropriate theoretical framework. Whose theory addresses the four modes of adaptation? A. Martha Rogers B. Sr. Callista Roy C. Florence Nightingale 10/53 D. Jean Watson 49. He opts to use a self-report method. Which of the following is NOT TRUE about this method? A. Most direct means of gathering information B. Versatile in terms of content coverage C. Most accurate and valid method of data gathering D. Yields information that would be difficult to gather by another method 50. Which of the following articles would Kevin least consider for his review of literature? A. “Story-Telling and Anxiety Reduction Among Pediatric Patients.” B. “Turnaround Time in Emergency Rooms.” C. “Outcome Standards in Tertiary Health care Institutions.” D. “Environment Manipulation and Client Outcomes.” 51. Which of the following variables will he likely EXCLUDE in his study? A. Competence of nurses B. Caring attitude of nurses C. Salary of nurses D. Responsiveness of staff 52. He plans to use a Likert Scale to determine A. Degree of agreement and disagreement B. Compliance to expected standards C. Level of satisfaction D. Degree of acceptance 53. A patient in the ICU is status post embolectomy after a pulmonary embolus. What does the nurse measure on a patient who is postoperative from an embolectomy? A. Left atrial pressure B. Pressure in the vena cava C. Pulmonary venous pressure D. Pulmonary arterial pressure 54. A 52 year old mother of three has just been diagnosed with lung cancer. The physician discusses treatment options and makes recommendations to this patient. After the physical leaves the room, the patient asks the nurse how the treatment is decided on. What would be the nurse’s best response? 11/53 A. “The type of treatment depends on the patient’s age and health status.” B. “The type of treatment depends on what the patient wants when given the options.” C. “The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the patient’s heath status.” D. “The type of treatment depends on the discussion between the patient and the physician of which treatment is best.” 55. Chest trauma to at least one of the several pathologic states; what are they? Select all that apply. A. Hypovolemia B. Cardiac failure C. Pulmonary embolus D. Hypoxemia E. Aortic rupture 56.The occupational health nurse is assessing new employee at her company. What would be important to assess in employee with a potential occupational respiratory history? (Mark all that apply.) A. Time frame of exposure B. Effectiveness of respiratory protection used C. General hygiene D. Outside interests E. Other areas lived 57. The home care nurse is planning to begin retraining exercises with a client newly admitted to the home health service. The home care nurse knows that breathing restraining is especially indicated in patients with which diagnosis? A. Emphysema B. Chronic bronchitis C. Lung cancer D. COPD 58. You are caring for a client who is scheduled for a PTCA this evening. The patient asks you what complications can happen during the procedure. What should the nurse answer? A. “Complications that can occur during a PTCA include dissection of the ductusarteriosa.” B. “Complications that can occur during a PTCA include hyposensivity of the heart muscle.” C. “Complications that can occur during a PTCA include vasospasm of the coronary artery.” 12/53 D. “Complications that can occur during a PTCA include closure of the pulmonary artery.” 59. You are caring for a patient who has developed pulmonary edema. What is a priority nursing action? A. Lay the patient flat B. Notify the family of patient’s critical state C. Stay with the patient D. Call the physician 60. A patient presents to the emergency department complaining of severe headaches, nosebleeds, and anxiety. What might the nurse suspect is the protein with this patient? A. Hypertensive emergency B. Hypertensive crisis C. Hypertension D. Hypertensive urgency 61. A nurse is teaching a female client newly diagnosed with Helicobacter pylori infection. The nurse anticipated that which medication will not be used learning the client is pregnant? A. Metronizadole B. Amoxicillin C. Clarithromycin D. Ciprofloxacin 62. A 3 month old infant is diagnosed with leukemia. Which of the following does the nurse anticipate ill part of the plan of care for this infant? A. The baby will be placed in isolation B. Leukemia is familial and other children should be assessed C. Immunizations will be withheld during exacerbations D. The baby will be NPO during chemotherapy 63. The registered nurse is assigned to the postpartum unit. Which task could the RN safely delegate to a beginning student nurse? A. Ambulate a client who delivered cesarean 2 days ago B. Complete the admission assessment on a newly delivered client C. Call the physician to report a low hemoglobin level D. Verify a unit of blood prior to transfusion 13/53 64. A client with cancer has a calcium level of 11.8mg/dL. Which symptom would indicate a need for the nurse to call the physician for treatment orders? A. Increased gastric motility B. Peaked T waves on 12 lead ECG C. Muscle spasms D. Muscle weakness 65. A patient presents to the emergency department complaining of severe headaches, and anxiety. What might the nurse suspect s the problem with this patient? A. Hypertensive emergency B. Hypertensive crisis C. Hypertension D. Hypertensive urgency 66. The nurse is assessing the chart of a client with a stroke. MRI results reveal a hemorrhage stroke to the brain. Which physician prescription would the nurse question? A. Normal saline IV at 50mL/hr B. 02 at 3L/min by nasal cannula C. Heparin infusion per pharmacist protocol D. Insert a Foley catheter 67. The nurse is assessing an ECG strip for a 42 year old client and finds a regular rate greater than 100, a normal QRS complex, a normal P wave in front of each QRS, a PR interval between 0.12 and 0.20 seconds, and a p: QRS ration 1:1. What is the nurse’s interpretation of this rhythm? A. Premature atrial complex B. Sinus tachycardia C. Atrial flutter D. Supravetricular tachycardia 68. The client who’s a member of Jehovah’s Witness refuses a blood transfusion based on his religious beliefs and practices. His decision must be followed based on which ethical principle? A. The right to die B. Advance directive C. Autonomy of the client D. Substituted judgment 14/53 69. Which statement by a student nurse demonstrates that further instruction about cyotoxic drugs is a needed? A. “Cytotoxic parenteral infusion containers should be marked with a special hazard labels.” B. “Infusion set administration connections should be tight.” C. “Nurses who are pregnant must wear gloves during administration of cyotoxic drug.” D. “The infusion line should be primed into a gauze inside a sealable plastic bag.” 70. A nurse is talking with a delusional client when the fire alarm sounds and a staff member closes the door to the client’s room. The client becomes very agitated and declares, “The aliens have arrived!” which actions are appropriate for the nurse to take? Select all that apply. A. Leaving the room but telling the client she’ll return soon B. Telling the client that there’s no danger and that everything’s fine C. Telling the client that the alarm is just a drill and that he shouldn’t be afraid. D. Staying with the client until she receives further instructions E. Continuing to speak to the client in a reassuring tone 71. A graduate nurse is reviewing the procedure for removing a peripherally inserted central catheter (PICC. With her preceptor. Which planned action by the graduate nurse should the preceptor correct? A. Measuring the length of the removed catheter and comparing it with the documented length of the inserted catheter. B. Discarding the catheter in a trash container C. Flushing the PICC with 0.9% sodium chloride before removing it. D. Applying a dressing over the site and leaving it in place for 24 hours 72. Moments after birth, a neonate of 32 weeks’ gestation develops asphyxia. As a neonatal team starts resuscitation, the nurse must: A. Hyperextend the neonate’s neck B. Keep the neonate’s head in the “sniff” position. C. Maintain the neonate’s head in a neutral position D. Turn the neonate’s head slightly to one side 73.A charge is making arrangements for an elderly client newly admitted from the emergency department for treatment of suspected pyleonephritis. The charge nurse noted that the client has been assigned to a semiprivate room with another client who has the same last name. What should the nurse do first? A. Make signs to alert staff members that both clients in the room have the same last name 15/53 B. Ask the admissions department to assign the elderly client to a new room C. Ask the client if he’d be willing to answer to a different last name D. Verbally remains the staff to check client’s identification bracelet before administering medications 74. After an upsetting divorce, a client who threatens to commit suicide with a handgun is voluntarily admitted to the psychiatric until with major depression. Which nursing diagnosis takes highest priority for this client? A. Hopelessness related to recent divorce B. Ineffective coping related to inadequate stress management C. Spiritual distress related to conflicting thought about suicide and sin D. Risk for self directed violence related to planning to commit suicide with a handgun 75. A client recruited to participate in a clinical trial to treat non-Hodgkin’s lymphoma tells a nurse and physician that he’s willing to start the trial, but doesn’t know if adverse effects of the treatment will prevent him from completing it. To protect the ethical principle of autonomy, the nurse tell the client: A. How long the trial will last B. The name of the company sponsoring the trial C. That he may withdraw at any time D. The risks and benefits associated with trail participation 76. A client admitted with bacterial meningitis must be transported to the radiology department for a repeat computed tomography scan of the head. His level of consciousness is decreased, and he required nasopharyngeal suctioning before transport. Which infection control measures are best when caring for this client? A. Use standard precautions, which require gloves for suctioning B. Put on gloves, a mask ,and eye protection C. Put on gloves, a mask, and eye protection during suctioning, and then apply mask to the client’s face for transport. D. Take no special precautions for this client 78. For an infant who’s undergoing a lumbar puncture, the nurse should place the infant in: A. An arched, side-lying position , with the neck flexed onto the chest B. An arched, side-lying position, avoiding flexion of the neck onto the chest 16/53 C. A mummy restraint D. A prone position, with the head over the edge of the head 79. A nurse observes a nursing assistant bending over a bed as she helps an obese client sit up. The nurse discusses her observations with the nursing assistant to reinforce the need for proper body mechanics. Which response indicates that the nursing assistant understands these principles? Select all that apply. A. “I need to keep my back straight and lift with my tight muscles.” B. “I need to keep my elbows bent and use my thigh muscles to bear the weight.” C. “I should bend at the knees , keep my back straight, then pull the client up.” D. “I should stand at the client’s side, grasp the draw sheet, and pull the client up.” 80. After a traumatic back injury, a client skeletal traction. Which intervention takes priority? A. Monitoring the client for skin breakdowns B. Maintain traction continuously to ensure its effectiveness C. Supporting the traction weights with a chair or table to prevent accidental slippage D. Restricting the client’s fluid and fiber intake to reduce the movement required for bedpan use 81. A client with sever acute respiratory syndrome privately inform a nurse that he doesn’t want to be placed on a ventilator if his condition worsens. The clients wife and children repeatedly expressed their desire that every measure be taken for the client. The most appropriate action by the nurse would be to: A. Inform the family of the client wishes B. Assure the family that all possible measures will be taken. C. Support the client’s decision D. Assure the client that all possible measures will be taken’ 82. A nurse is caring for a client who is scheduled for a anibuicenetisis. What information about the procedure should the nurse provide before the client signs the consent form? A. Name of procedure, how its performed, description of alternate methods available, potential risk to monitor and fetus, risks associated if the procedure isn’t performed. B. Name of procedure , risk to mother, name of physician who will perform procedure C. Name of procedure, risk to the fetus D. Description of alternate methods available, duration of the procedure, day and time the scheduled procedure will be performed 17/53 83. A client , who is bound to a wheelchair, comes to the clinic for follow up evaluation of pressure ulcers on his buttocks. The client reports that his family has been changing his hydrocolloid dressings every 3 to5 days. During the past weeks, he has been spending less time in his wheelchair, and when he does use the wheelchair he uses a cushion. During his appointment the nurse notes that he isn’t using a cushion, and that the wound is covered with a dry sterile dressing. How should the nurse approach the client about his treatment regimen? A. Do nothing because the client is able to make his own care decisions B. Tell the client not to return to the clinic because he isn’t following the treatment plan. C. Explain pressure ulcer development in terms he understands D. Provide a brief anatomy and physiology lesson on how pressure ulcers develop 84. The nurse identifies which of the following clients as being at HIGHEST risk for injury? A. A 3month old child is in an infant seat that he mother places on the coffee table B. A 2 year old is laying alone in the living room C. A 2 ½ year old with a tracheotomy is eating raisins D. A 10 year old stays home alone for half an hour after school 85. The nurse supervises an LPN/LVN provide care to a patient with an infected abdominal wound. The nurse noted a Penrose drain in place and the wound is draining copious amount of purulent drainage, the nurse determines care is appropriate if which of the following is observed? A. The LPN/LVN dons clean gloves, removes the soiled dressing, and puts on a pair of clean gloves to dress the wound. B. The LPN/LVN dons clean gloves, removes the soiled dressing, changes to sterile gloves, and uses sterile dressing to cover the wound. C. The LPN/LVN dons sterile gloves, removes the soiled dressing, changes to clean gloves, uses sterile dressings to cover the wound. D. The LPN/LVN places the client in protective isolation, removes the old dressings using sterile gloves, and applies sterile dressing using sterile technique. 86. The nurse on the surgical unit administers an incorrect dose of medication to the client. The nurse should take which of the following actions? Select all that apply: A. Record the dose of medications administered B. Photocopy the incident report for the nurse’s personal files C. Perform an assessment of the client D. Contact the physician 18/53 E. Chart any adverse reaction the client experienced F. Submit the report to the risk manager with 48 hours 87. The nurse returns to a senior center to evaluate the effectiveness of a presentation about how to prevent falls among seniors. The nurse determines that teaching was effective if the seniors state which of the following? A. “I started taking Tai Chi classes.” B. “I have a new pair of athletic shoes with deep treads.” C. “I went to the eye doctor to have my vision checked.” D. “My physician reviewed all of my medications.” E. “I stopped exercising so I won’t fall.” F. “I brought some new lamps for my home.” 88. The nurse on the surgical unit administers an incorrect dose of medication to the client. The nurse should take which of the following actions? Select all that apply. A. Record the dose of medication administered B. Photocopy the incident report for the nurse’s personal files C. Perform an assessment of the client D. Contact the physician E. Chart any adverse reaction the client experienced F. Submit the report to the risk manager within 48 hours 89. A female college freshman visits the health center because she feels nervous, irritable, and extremely tired. She complains that, although eats large amounts of food, she has frequent bouts of diarrhea and is losing weight. The nurse observes a fine hand tremor, an exaggerated reaction to external stimuli, and wide-eyed expression. What laboratory tests may be ordered to determine to cause of these signs and symptoms? A. PTT and PT B. T3 , T4 and TSH C. VDRL and CBC D. ACTH, ADH, CRF 90. A client is receiving total parental nutrition through a subclavin vein. The nurse should: A. Place the client in the supine position before changing the tubing B. Monitor the blood pressure frequently to assess for hypovolemia 19/53 C. Decrease the infusion rate if blood glucose levels become elevated D. Administer intravenous antibiotics through this central line to prevent infection 91. A client with small-cell carcinoma of the lung develops the syndrome of inappropriate secretion of antidiuretic hormone (SIDAH). What responses to the secretion of antidiuretic hormone should the nurse expect when preparing caring for this client? Select all that apply. A. Edema B. Polyuria C. Bradycardia D. Hypotension E. Hyponatremia 92. A practitioner determines that a client has metabolic acidosis from severe dehydration. The characteristic respiration that the nurse expects with metabolic acidosis is: A. Dyspnea B. Hyperpnea C. Kussmaul’s breathing D. Cheyne-Stokes breathing 93. When a client is in profound (late.hypovolemic shock, the nurse assess the client’s laboratory values, especially the arterial blood gases. Which problem will people in late shock develop? A. Hypokalemia B. Metabolic acidosis C. Respiratory alkalosis D. Decreased Pco2 levels 94. when performing colostomy care, it is important for the nurse to teach the client to care for the skin around stoma by: A. Avoiding the use of soap and other irritating agents B. Rinsing with hydrogen peroxide and applying a gauze pad C. Pouring saline over the stoma and wiping away the fecal matter D. Washing the area gently with soap and water before applying an appliance 95. The clinic nurse instructs a client newly diagnosed with Raynaud Syndrome. Which of the following statements if made by the client to the nurse indicates the need for further teaching? 1. “I will warm up my car before I get in and start to drive.” 20/53 2. “I am going to my yoga class after I leave the clinic.” 3. “I will first place my fingers in warm, then cool, then cold water three times a day.” 4. “I am going to make coffee and cigarettes a thing of a past.” 96. The nurse cares for a client receiving albuterol (Proventil) 2 puffs, and beclomethasone (Vanceril) 2 puffs through inhalers. The nurse should include which of the following statements when counseling the client? 1. “Use of the Proventil inhaler and then use the Vanceril inhaler.” 2. “Use the vanceril inhaler and then the Proventil inhaler.” 3. “You should take 1 puff of each inhaler, wait a minute, and then repeat the process.” 4. “Either inhaler can be used first as long as you wait 2 minutes between puffs. “ 97. The nurse obtains a history from a client scheduled to undergo electroconvulsive therapy. It is MOST important for the nurse to report which of the following findings to the physician? 1. The client takes alendronate (Fosamax) once a day. 2. The client complains of lethargy and fatigue 3. The client has received electroconvulsive therapy in the past 4. The client walks for 30 minutes three times per week. 98. An infant is treated in the newborn nursery for hyperbilirubinemia using a photocopy lights. It is MOST important for the nurse to intervene in which of the following situations? 1. The mother turns off the phototherapy lights and removes the infant’ eye patches in preparation 2. The mother is worried because the infant experiences frequent loose, greenish stools and increased urine output 3. A laboratory technician turns off the phototherapy lights to draw blood. 4. The jaundice observed the infant’ s eyes has begun to disappear 99. What is the MOST effectively way for the nurse to prevent unnecessary complications for a patient receiving medications in the acute care setting ? 1. Encourage the patient to report any new or unusual symptoms to the nurse or physician immediately 2. Obtain information regarding the patient’s allergies and document in the chart an allergy armband 3. Monitor the patient’s response to prescribed medications 4. Offer patient information regarding medications before administration 21/53 100. The nurse instructs a client receiving captopril (Capoten) 25mg TID. Which of the following statements, if made by the client, indicates that further teaching is necessary? Select all that apply A. “I will take the medication 1 hour before meals B. “I should increase any intake of potassium.” C. “I will cook with a salt substitute.” D. “If I mass a dose, I can take two pills at the next scheduled time.” E. “I should take the medication at the same time every day.” F. “I should change positions slowly.” 101. The nurse instructs the parents of a 6 year old boy about the medications prescribed by the clinic physician. The physician’s order reads, “Phenobarbital 15 mg PO q12h, phenytoin sodium (Dilantin) 30 mg/5 ml BID.” Which of the following information is MOST important for the nurse to discuss with the parents? A. B. C. D. Dilantin comes as a suspension and should be shaken. Dilantin can cause a change In the growth of the boy’s gums Phenobarbital can cause a discoloration of the child’s urine Phenobarbital can affect the child’s vitamin D metabolism 102. The nurse teaches the mother of an infant how to care for her infant following repair of a cleft lip. It is MOST important for the nurse to include which of the following instructions 1. “Feed the infant with a newborn nipple while holding him in the recumbent position.” 2. Clean the suture site with a cotton-tipped swab soaked in Betadine.” 3. “Place the infant in the prone position after feeding.” 4. Feed the infant with a rubber-tipped syringe and bubble frequently. “ 103. The nurse cares for a client receiving furosemide (Lasix). The nurse determine that teaching is effective if the client selects which of the following foods? 1. One medium baked potato 2. One slice of white blood 22/53 3. 4. 5. 6. One medium apple One scrambled egg 1 ¼ cup of corn flakes I cup of cantaloupe 104. The nurse supervises care of a client in Buck’s traction. The nurse determines that care is appropriate if which of the following is observed? Select all that apply: 1. The nurse removes the foam boot three times per day to inspect the skin 2. The staff turn the client to the unaffected side 3. The staff provides back care for the client once per shift 4. The nurse asks the client to dorsiflex the foot on the affected leg 5. The staff offers magazines to the client when she complains of pain. 6. The staff elevates the foot of the client’s bed 105. The nurse instructs a client 5 days after a lumbar laminectomy with spinal fusion about how to move from a supine position to standing at the left side of the bed with a walker. Which of the following directions by the nurse is BEST? 1. Raise the head of the bed so you are sitting straight up, bend your knees, and swing your legs to the side and then to the floor. 2. Rock your body from side to side, going further each time until you build up enough momentum to be lying on your right side, and then raise your trunk toward your toes. 3. Reach over to the left side rail with your right hand, pull your body onto its side, bend your upper leg so the foot is on the bed, and push down to elevate your trunk 4. Focus on using your arms, the left elbow as a pivot with the left hand grasping the mattress edge and the right hand pushing on the mattress above the elbow, then slide your legs over the side of the mattress 106. The nurse counsels a client diagnosed with iron deficiency anemia. The nurse determines that teaching is effective if the client selects which of the following menus? 1. 2. 3. 4. Roast beef, brown rice, green beans, carrot and raisin salad, and milk. Cheese pizza, tossed green salad, oatmeal-raisin cookie, and lemonade Two scrambled eggs, bacon, white toast with strawberry jam, and coffee Corn flakes with milk, whole wheat toast, and orange juice 23/53 107. The nurse supervises care of a client who is receiving enteral feeding via a nasogastric tube. The nurse determines that care is appropriate if which of the following is observed? Select all that apply: 1. 2. 3. 4. 5. 6. The nursing assistant aspirates and measures the amount of the gastric aspirate The nursing assistant elevates the head of the client’s bed 30 degrees The nursing assistant warms the formula to room temperature The nursing assistant measures the pH of the gastric aspirate The nursing assistant infuses the intermittent feeding in 20 minutes The nursing assistant clamps the proximal end of the feeding tube at the end of the feeding 108. The nurse performs a physical assessment of a newborn. It is MOST important for the nurse to report which of the following findings? 1. 2. 3. 4. Head circumference of 40 cm Chest circumference of 32 cm Acrocyanosis and edema of the scalp Heart rate of 160 bpm and respirations of 40/min 109. The nurse in the pediatric clinic performs a physical assessment of a 13 year old boy. Which of the following findings by the nurse requires an immediate intervention? 1. The adolescent complains of his scotum aching after exercise. The nurse palpated a worm like mass above the testes 2. The nurse noted unilateral breast enlargement 3. The child’s scrotum appears swollen, and a soft mass is palpated. The nurse is unable to insert a finger above the mass 4. The child’s scrotum appears enlarged and red. The nurse palpated a thickened and swollen spermatic cord. 110. The nurse on the medical/ surgical unit a client with a diagnosis of cerebrovascular accident (CVA. The nursing assessment of the client’s neurological status should include which of the following? 1. 2. 3. 4. 5. 6. Obtain the pulses in all four extremities. Ask the client to grasp and squeeze tow fingers on each of the nurse’s hands. Determine client’s observation to person, place, and time Determine if the client has pain when walking Observe for the presence of Chadwick’s sign Assess the client‘s papillary response 24/53 111.A nurse is caring for a client with a diagnosis of catatonic schizophrenia. What clinical finding does the nurse expect the client to exhibit? A. B. C. D. Crying Self-mutation Immobile posturing Repetitious activities 112. A client with type 1 diabetes is diagnosed with diabetic ketacidosis and initially treated with intravenous fluids followed by an IV bolus of regular insulin. The nurse anticipates that the practitioner will prescribe continuous infusion insulin of: A. B. C. D. Novolin L insulin Novolin R insulin Novolin N insulin Novolin U insulin 113. A client is admitted to the hospital with the diagnosis of a right-sided brain attack ( CVA. The client is right handed. Which task will be most difficult for this client? A. B. C. D. Eating meals Writing letters Combing the hair Dressing every morning 114. The nurse understands that which are characteristics of anthrax? Select all that apply. A. B. C. D. E. F. It is caused by the bacillus Yesinia petis Cutaneous lesions become a black eschar Gastrointestinal anthrax causes blood anthrax Flulike symptoms are a sign of pulmonary anthrax Person to person transmission of inhalation disease does not occur A person can become infected through skin contact, ingestion, or inhalation of the bacillus 115. The nurse is caring for a client who religious background is Seventh Day Adventist (Church of GOD. Which nursing action(s) are most appropriate in terms of providing for the dietary needs for this client? Select all that apply. A. B. C. D. E. Providing snacks between each meal Providing wine with dinner as requested Removing coffee from the breakfast tray Ensuring that there is no port on the dinner tray Ensuring that meals are delivered in a timely fashion 25/53 116. The nurse prepares to administer digoxin (Lanoxin) to a newborn with a diagnosis of heart failure and notes that the apical rate is 140 beats per minute. Which nursing action is appropriate? A. B. C. D. Hold the medication Administer the digoxin Notify the health care provider Recheck the apical rate in 1 hour 117. The nurse is conduction a respiratory assessment and is determining respirations per minute. The nurse understands that which factor(s) generally affect the character of respirations? Select all that apply. A. B. C. D. E. F. Anxiety Exercise Smoking Acute pain Body position Musculoskeletal disorders 118. The nurse understands that which are judgmental statements (s)? select all that apply. A. “I don’t think you need to do that.” B. “I would like to be sure I understood” C. “Tell me about making that decision.” E. “I’m not sure that’s what is best for you.” F.”When did you first notice you felt that way.” 119. The nurse is planning to teach a client about home modifications to reduce the risk of falls. Which recommendations (s) should be included in the teaching plan? Select all that apply. A. B. C. D. E. Remove wall to wall carpeting Use nightlights during nighttime Place handrails in bathtubs and showers Check staircase railings for secureness and sturdiness Place scatter rugs in hardwood floors and at the bottom of a staircase 120. A client is diagnosed with myasthenia gravis and the nurse needs to administer a medication to this client. Number the actions in this options in order of priority with regard to how the nurse should perform the actions (Number 1 is the first action to be performed and number 6 is the last action) 26/53 3. Assess swallowing ability 2. Elevate the head of the bed 1 check the medication prescription 4 Administer precisely at prescribed time 5 document administration of the medication 6 Monitor responses to medication as the day progresses 121. The nurse is preparing to assist in examining a Hispanic child who was brought to the clinic by the mother. During the assessment of the child, the nurse should take which action(s)? Select all that apply. A. B. C. D. E. F. Admiring the child Taking the child’s temperature Including the child in the discussion Obtaining an interpreter if necessary Making direct eye contact with the mother Asking the mother questions about the child 122. The nurse understands that personal health information can be disclosed in which situation(s)? Select all that apply. A. B. C. D. E. Compliance with legal proceedings For research purposes in limited circumstances To a family member or significant other in an emergency To nonessential medical personnel involved in client care To appropriate military if a client is a member of the armed forces 123. The nurse had developed a close relationship with the family of a client who is dying. Which nursing intervention(s) are most appropriate in dealing with the family? Select all that apply. A. B. C. D. E. F. Encouraging family discussion of feelings Accepting the family’s experience of anger Restricting client visits to scheduled hospital visiting hours Facilitating the use of spiritual practices identified by the family Keeping the family informed of change in the client’s condition Making the decision for that family during the difficult moments 27/53 124. The nurse has given post procedure instructions to a client who underwent a colonoscopy. Evaluation of learning would be evident if the client makes which statement(s)? select all that apply. A. B. C. D. E. F. “It is all right to drive once I’ve been home for an hour or so.” “My abdominal muscles may be tender because of the procedure.” “My diet should be light as first, and then I can progress to a regular diet.” “It is normal to feel gassy or bloated for short while after the procedure.” “I should expect to have a moderate amount of blood in my stool for the new days.” “If I develop a fever following the procedure, I should call the health care provider 125. Which nursing action(s) can result in disciplinary action by state boards of nursing? Select all that apply. A. B. C. D. E. Release of client health information to a client’s neighbor Delegation of a dressing change to unlicensed assistive personnel (UAP) Release of client health information to the client’s durable power of attorney Administration of a routine immunization that resulted in an allergic reaction. Administration of an injection to a client who stated refusal of the medication 126. The nurse on the postsurgical unit received a client that was transferred from the postanesthia care unit (PACU) and is planning care for this client. The nurse understands that staff should begin planning for this client’s discharge at which point during the hospitalization? A. B. C. D. Is admitted to the surgical unit Is transferred from the PACU to the postsurgical unit Is able to perform activities of daily living independently Has been assessed by the health care provider for the first time after surgery 127. The nurse acts as a client advocate in which situation(s)? Select all that apply. A. B. C. D. E. Pulling the curtain around the client’s bed while changing a dressing Contacting the health care provider to request a meeting for the client Ensuring access to medical information by appropriate personnel only Providing the client with request information regarding support groups Questioning the health care provider regarding a discrepancy in reported medication dosages between the home and hospital setting 128. The nurse enters a client’s room and the client is demoting release from the hospital. The nurse reviews the client’s record and noted that the client admitted 2 days ago for treatment of anxiety disorder that the admission was voluntary. Which intervention should the nurse initiate first? 28/53 A. B. C. D. Telephone the client’s family, and have the persuade the client to stay Have the client read and sign all of the appropriate self-discharge papers Explain to the client that he cannot leave because he asked for treatment Notify the client’s health care provider of the client’s stated intent to leave the hospital. 129. A client scheduled for surgery cannot sign the operative consent form because he has been sedated with opoid analgesics. The nurse should take which best action regarding the informed consent? A. B. C. D. Obtain a court order for the surgery Sign the informed consent on behalf of the client Send the client to surgery without the consent formed being signed Obtain a telephone consent from the family member, with the consent being witnessed by two health care providers 130.For which client situation would a consultation with a rapid response team (RRT) be most appropriate? A. 45 year old; 2 years post kidney transplant; second hospital day for treatment of pneumonia; no urine output for 6 hours; temperature 101.4 degree Fahrenheit; heart rate of 98 beats per minutes; respirations 20 breaths per minute; blood pressure 88/72 mm hg; is restless B. 72 year old; 24 hours after removal of a chest tube that was used to drain pleural fluid (effusion); temperature 97.8 F; her rate 92 beats per minute; respiration 28 breaths per minute; blood pressure 132/ 86 mm hg; anxious about going home C. 56 year old fourth hospital day after coronary artery bypass procedure; sore chest; pain with walking temperature 97 degree F; heart rate 84 beats per minute; respirations 22 breaths per minute; blood pressure 87/72 mmHG; bored with hospitalization. D. 86 year old’ 48 hours postoperative repair of fractured hip (nail inserted; alert; oriented; using patient-controlled analgesia (PCA . pump; temperature 96.8F; heart rate 60 beats per minute; respirations 16 breaths per minute; blood pressure 90/62 mmHg; talking with daughter. 131. Which situation(s) are classified as natural disasters? Select all that apply A. B. C. D. E. Blizzards Terrorist attacks Volcanic eruptions Structural collapse Communicable diseases 132. The nurse is analyzing laboratory values for the assigned clients. Which finding, based on the clients medical history, indicates the need for immediate follow-up? 29/53 A. B. C. D. Client with chronic kidney disease and serum creatinine of 1.6 mg/dL Client with diabetes mellitus and a glycoslated hemoglobulin A (HbA1c of 70% Client with a heart failure and a B-type natruretic peptide (BNP) of 140 pg/mL Client who is male and has anemia with hemoglobin of 16.5 g/dL and hematocrit of 45% 133. The hypertonicity of the muscles in an infant with cerebral palsy causes scissoring of the legs. The nurse teaches the mother that the preferred way to carry the infant is in a sitting position: A. B. C. D. Astride one of her hips Strapped in an infant seat Wrapped tightly in a blanket Under the arm using a football hold 134. The nurse administers 2 unites of salt-poor albumin to a client with portal hypertension and ascites. The nurse explain to the client that this is administered to: A. B. C. D. Provide nutrients Increase protein stores Elevate the circulating blood volume Divert blood flow away from the liver temporarily 135. A 31 year old client is seeking contraceptive information. Before responding to the client’s question is about contraceptives, the nurse obtains a heath history. What factor in the client’s history indicates to the nurse that oral contraceptives are contraindicated? A. B. C. D. More than 30 years of age Had two multiple pregnancies Smokes 1 pack of cigarettes a day Has a history of borderline hypertension 136. A nurse administers albuterol to a child with asthma. For what common side effect should the nurse monitor the child? A. B. C. D. Flushing Dyspnea Tachycardia Hypotension 138. Before administering an MMR (measles, mumps, and rubella) vaccine to a 15 month old, which question should the nurse ask the mother of the child? A. “Has your child had any sore throats?” B. “Has your child been eating properly?” 30/53 C. “Is your child allergic to any antibiotic?” D. “Has your child been exposed to any infectious?” 139. A nurse is caring for an 8 year old child who is admitted to the pediatric unit with a tentative diagnosis of acute postreptococcal glomerulonphritis (ASPGN). Diagnostic tests are ordered. Which tests will help confirm the diagnosis? Select all that apply. A. ASO titer B. Urinalysis C. Blood Chemistry D. Intravenous pyleogram E. Chest X-ray examination 140. A nurse is reviewing the health history and laboratory report of a child with lead poisoning. What complications does the nurse expect in relation to lead toxicity? Select all that apply. A. Anemia B. Urinalysis C. Blood chemistry D, Intravenous pyleogram E. Chest X-ray examination 141. Six hours after major abdominal surgery a male client complains of severe abdominal pain; is pale and perspiring; has a thread, rapid abuse pulse; and states he feels faint. The nurse checks the client’s medication administration record and determines that the client receives another injection of pain medication in an hour. What is appropriate action by the nurse? A. B. C. D. Explain to the client that is too early to have an injection for pain Call the practitioner, report the client’s symptoms, and obtain further orders Reposition the client for greater comfort and turn on the television as a distraction Prepare the injection and administer it to the client early because of the severe pain 142. A client is ordered lisinopril (Zestril) for treatment of hypertension. He asks the nurse about possible adverse effects. The nurse should him about which common adverse effects of antigotensin-converting enzyme (ACE. Inhibitors? Select all that apply. A. B. C. D. E. F. Constipation Dizziness Headache Hyperglycemia Hypotension Impotence 31/53 143. A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client’s fluid status? A. B. C. D. Measuring and recording fluid intake and output Weighing the client daily at the same time each day Assessing the client’s vital signs every 4 hours Checking the client’s lungs for crackles during every shift 144. A client is transferred from the emergency department to the locked psychiatric until after attempting suicide by taking 200 acetaminophen (Tylenol) tablets. The client is now awake an alert but refuses to speak with the nurse. In this situation, the nurse’s first priority is to: A. B. C. D. Establish a rapport to foster trust Place the client in full restraints Try to communicate with the client in writing Ensure safety by initialing suicide precautions 145. Which potential complication should the nurse assess for in the client with infective endocarditis who has embolization of vegetative lesions from the mitral valve? A. B. C. D. Pulmonary embolus Decreased urine output Hemoptysis Deep vein thrombosis 146. The client has just had a pericardiocentesis. Which interventions should the nurse implement? Select all that apply. A. B. C. D. E. Monitor vital signs every 15 minutes for the first time Assess the client’s heart and lung sounds Record the amount of fluid removed as output Evaluate the client’s cardiac rhythm Keep the client in the supine position 147. The nurse is caring for clients on a cardiac floor. Which client should the nurse assess first? A. B. C. D. The client with three (3) unifocal PVC’s in a minute The client diagnosed with coronary artery disease that wants to ambulate The client diagnosed with mitral valve prolapsed with an audible S3 The client diagnosed with pericarditis that is in normal sinus rhythm 148. The nurse is told in report that the client has aortic stenosis. Which anatomical position should the nurse auscultate to assess the murmur? A. Second intercostals space, right sterna notch 32/53 B. Erb’s point C. Second intercostals space, left sternal notch D. Fourth intercostals space, left sternal border 149. The nurse is caring for a client who goes into ventricular tachycardia . which interventions should the nurse implement first? A. B. C. D. Call a code immediately Assess the client for a pulse Begin chest compressions Continue to monitor the client 150. The nurse is assisting with a synchronized on a client in atrial fibrillation. When the machine is activated, there is a pause. What action should the nurse take? A. B. C. D. Wait until the machine discharges Shout “all clear” and don’t touch the bed Make sure the client is all right Increase the joules and redischarge 151. The client is diagnosed with pericarditis. When assessing the client, the nurse is unable to asculate a friction rub. Which action should the nurse implement? A. B. C. D. Notify the health care provider Document that the pericarditis has revolved Ask the client to lean forward and listen again Prepare to insert a unilateral chest tube 152. The nurse is teaching basic cardiopulmonary resuscitation (CPR) to individuals in the community. Which is the order of basic CPR? List in order of performance A. B. C. D. E. Perform head tilt chin lift Give two (2) rescue breaths Look, listen, and feel for breathing Begin cardiac compressions Shake and shout 153. which question should the nurse ask the male client diagnosed with aorto-iliac disease during the admission interview? A. B. C. D. “Do you have trouble sitting for long periods of time?” “How often do you have a bowel movement and urinate?” “When you lie down do you feel throbbing in your abdomen?” “Have you experienced any problems having sexual intercourse?” 33/53 154. The client is four (4) hours post-operative abdominal aortic aneurysm repair. Which nursing intervention should be implemented for this client? A. B. C. D. Assist the client to ambulate Assess the client’s bilateral pedal pulses Maintain continuous IV heparin drip Provide a clear liquid diet to the client 155. Which referral would be most appropriate for the client diagnosed with thoractic outlet syndrome? A. B. C. D. The physical therapist The thoractic surgeon The occupational therapist The social worker 156. Which instructions should the nurse discuss with the client diagnosed with Raynaud’s phenomenon? A. B. C. D. Explain exacerbations will not occur in the summer Use nicotine gum to help quit smoking Wear extra warm clothing during cold exposure Avoid prolonged exposure to direct sunlight 157. The client diagnosed with diabetes mellitus type 2 is admitted to the hospital with cellulitis of the right foot secondary to an insect bite. Which intervention should the nurse implement first? A. B. C. D. Administer intravenous antibiotics apply Warm moist packs every two (2) hours Elevate the right foot on two (2) pillows Teach the client about skin and foot care 158. Which discharge instruction should the nurse teach the client diagnosed with varicose veins who has received sclerotherapy? A. B. C. D. Walk 15 to 20 minutes three (3) times a day. Keep the legs in the dependant position when sitting Remove compression bandages before going to bed Perform Berger-Allen exercises (4) times a day 159. The nurse is teaching the client with peripheral vascular disease. Which intervention should the nurse discuss with the client? Select all that apply. A. Wash your feet antimicrobial soap 34/53 B. C. D. E. Wear comfortable, well-fitting shoes. Cut your toenails in an arch Keep the area between the toes dry Use a heating pad when feet are cold 160. The unlicensed nursing assistant is applying elastic compression stockings to the client. Which action by the assistant warrant immediate intervention by the nurse? A. B. C. D. The assistant is putting the stockings on while the client is in the hair The assistant inserted two (2) fingers under the proximal end of stocking The assistant elevated the feet while lying down to putting on the stockings. The assistant made sure the toes were warm after putting the stockings on 161. The nurse is administering a beta blocker to the client diagnosed with essential hypertension. Which data would cause to question administering the medication? A. B. C. D. The client’s BP is 110/70 The client’s potassium level is 3.4 mEq/L The client has a barky cough The client’s apical pulse is 56 162.The client diagnose with acute vein thrombosis is relieving a continuous heparin drip, an intravenous anticoagulant. The health care provider orders warfarin (Coumadin), an oral anticoagulant. Which action should the nurse take? A. B. C. D. Discontinue the heparin drip prior to initiating the Coumadin Check the client’s INR prior to beginning Coumadin Clarify the order with the health-care provider as soon as possible. Administer the Coumadin along with the heparin drip as ordered 163. The nurse is caring the client on strict bed rest. Which intervention is priority when caring for this client? A. B. C. D. Encourage the client to drink liquids Perform active range of motion exercises Elevate the head of the bed to 45 degrees Provide a high-fiber diet to the client. 164. The nurse is caring for clients on a medical floor. Which client will he nurse assess first? A. The client with an abdominal aortic aneurysm who is constipated B. The client on bed rest who ambulated to the bathroom C. The client with essential hypertension who has epitaxial and a headache 35/53 D. The client with atrial occlusive disease who has a decreased pedal pulse 165.The client with peripheral venous disease is scheduled to go to the whirlpool for dressing change. Which is the nurse’s priority intervention? A. B. C. D. Escort the client to the physical therapy department Medicate the client 30 minutes before going to whirlpool Obtain the sterile dressing supplies for the client Assess the client to the bathroom prior to the treatment 166. The nurse is caring for a client in a sickle cell crisis. Which is the pain regimen of choice to relieve the pain? A. B. C. D. Frequent aspirin (acetylsalicylic aciD. and a nonnarotic analgesic Motrin (ibuprofen), an NSAID, PRN Demerol ( meperidinE., a narcotic analgesic, every four (4) hours. Morphine, a narcotic analgesic, every two (2) to three (3) hours PRN 167. The client is diagnosed with hereditary spherocytosis. Which treatment/procedure would the nurse prepare the client to receive? A. B. C. D. Bone marrow transplant Splenectomy Frequent blood transfusions Liver biopsy 168. Which is the primary goal of care for a client diagnosed with sickle cell anemia? A. B. C. D. The client will call the HCP if feeling ill. The client will be complaint with medical regiment The client will live as normal a life as possible. The client will verbalize understanding of treatments 169. The client diagnosed with thalassemia, a hereditary anemia, is to receive a transfusion of packed RBCs. The cross-match reveals the presence of antibodies that cannot be cross-matched. Which precaution should the nurse implement when initiating the transfusion? A. B. C. D. Start the transfusion at 10-15 mL per hour for 15-30 minutes Re-crossmatch the blood unit the antibodies are identified Have the client sign a permit to receive uncrossmatched blood Have the unlicensed nursing assistant stay with the client 170. The client is complaining of painful swallowing secondary to mouth ulcers. Which statement 36/53 A. B. C. D. “I will brush my teeth with a soft-bristle toothbrush.” “I will rinse my mouth with Listerine mouth wash.” “I will swish my antifugunal solution and then swallow.” “I will avoid spicy foods, tobacco, and alcohol. 171. When assessing the integumentary system of the client with anorexia nervosa, which finding would support the diagnosis? A. B. C. D. Preoccupation with calories Thick body hair Sore tongue Dry, brittle hair 172. The nurse is teaching the client diagnosed with colon cancer who is scheduled for acolostomy the next day. Which behavior indicates the best method of apply adult teaching principles? A. B. C. D. The nurse repeats the information as indicated by the client’s questions The nurse teaches in one session all the information that the client needs The nurse uses a video so that the client hear the medical terms The nurse wait until the client asks questions about the surgery. 173. The nurse is caring for the client one (1) day postoperative sigmoid colostomy operation. Which independent nursing intervention should the nurse implement? A. B. C. D. Change the infusion rate of the intravenous fluid Encourage the client to discuss his or her feelings Administer opiod narcotic medications for pain management Assist the client out of bed to sit in the chair twice daily 174.The nurse is caring for the client recovering from intestinal surgery. Which assessment finding would require immediate intervention? A. B. C. D. Presence of thin park drainage in the Jackson Pratt Guarding when the nurse touches the abdomen Tenderness around the surgical site during palpation Complaints of chills and feeling feverish 175. The client has been diagnosed with hemorrhoids. Which statement from the client indicates that further teaching is needed? A. “I should increase fruits, bran, and fluids in my diet.” B. “I will use warm compresses and take sitz baths daily.” C. “I must take a laxative every night and have a stool daily.” 37/53 D. “I can us an analgesic ointment or suppository for pain.” 176. The nurse is preparing postoperative nursing care plan for the client recovering from a hemorrhoidectomy. Which intervention should the nurse implement? A. B. C. D. Establish a rapport with the client to decrease embarrassment of assessing site Encourage the client to lie in the lithotomy position twice a day Milk the tube inserted during surgery to allow the passage of flatus. Digitally dilate the rectal sphincter to express old blood 177. The client has recently been diagnosed with irritable bowel syndrome (IBS). Which intervention should the nurse teach the client to reduce symptoms? A. B. C. D. Instruct the client to avoid drinking fluids with meals Explain the need to decrease intake of flatus-forming foods Teach the client how to perform gentle perianal care Encourage the client to see a psychologist 178. The client is admitted into the emergency department complaining acute epigastric pain and reports vomiting a large amount of bright red blood at home. Which interventions should the nurse implement? A. B. C. D. E. Assess the client’s vital signs Insert a nasogastric tube Begin iced saline lavage Start an IV with an 18 gauge needle. Type and crossmatch for a blood transfusion 179.The nurse is teaching a community class to people with Type 2 diabetes mellitus. Which explanation would explain the development of Type 2 diabetes? A. B. C. D. The insert cell in the pancreas stop producing insulin The client eats too many foods that are high in sugar The pituitary gland does not produce vasopressin The cells become resistant to the circulating insulin 180. The nurse is teaching the client diagnosed with Type 2 diabetes mellitus about diet. Which diet selection indicates the client understands the teaching? A. B. C. D. A submarine sandwich, potato chips, and diet cola Four (4) slices of a supreme thin-crust pizza and milk Smoked turkey sandwich, celery sticks, and unsweetened tea A roast beef sandwich, fried onion rings, and a cola 181. Which laboratory data indicate the client’s pancreatitis is improving? 38/53 A. B. C. D. The amylase and lipase serum levels are decreased The white blood cell count (WBC. Is decreased The conjugated and unconjugated bilibrubin levels are decreased The blood urea nitrogen (BUN) serum level is decreased 182. The client diagnosed with acute pancreatitis has developed a pseudocyst that ruptures. Which procedure should the nurse anticipate the HCP ordering? A. B. C. D. Parcentesis Chest tube insertion Lumbar puncture Biopsy of the pancreas 183. Which signs/symptoms would the nurse expect to find in the client diagnosed with an insulinoma? A. B. C. D. Nervousness, jitteriness, and diaphoresis Flushed skin, dry mouth, an tented skin turgor Polyuria, polydispsia, polyphagia Hypertension, tachycardia, and feeling hot 184. which risk factor would the nurse expect to find in the client diagnosed with pancreatic cancer? A. B. C. D. Chewing tobacco Low-fat diet Chronic alcoholism Exposure to industrial chemicals 185. The nurse is aware that noepinephrine are secreted by which endocrine gland? A. B. C. D. The pancreas The adrenal cortex The adrenal medulla The anterior pituitary gland 186. Which question should the nurse ask when assessing the client for an endocrine dysfunction? A. B. C. D. “Have you noticed any pain in your legs when walking?” “Have you had any unexplained weight loss?” “Have you noticed any change in your bowel movements?” “Have you experienced any joint pain or discomfort?” 39/53 187. Which nursing instruction should the nurse discuss with the client who is receiving glucocorticods for Addison’s disease? A. B. C. D. Discuss the importance of tapering medications when discontinuing medication Explain that the dose will need to be decreased during time of stress of infection Instruct the client to take medication on an empty stomach with a glass of water Encourage the client to wear Medic alert bracelet and carry a card in the wallet 188.The client with chronic alcoholism has chronic pancreatitis and hypomagnesaemia. What should the nurse assess when administering magnesium sulfate to the client? A. B. C. D. Deep tendon reflexes Arterial blood gases Skin turgor Capillary refill time 189. Which endocrine disorder would the nurse assess for in the client who has a closed head injury with increased intracranial pressure? A. B. C. D. Pheochromocytoma Diabetes insipidus Hashimoto’s disease Gynecomastia 190. The nurse has been assigned to train the unlicensed nursing assistant about prioritizing care. Which client should the nurse instruct the unlicensed nursing assistant to see first? A. B. C. D. The client who needed both sequential compression devices removed The elderly woman who needs assistance ambulating to the bathroom The surgical client who needs help changing the gown after bathing The male client who needs the intravenous fluid discontinued 191. The nurse is caring for the client recovering from a percutaneous renal biopsy. Which data indicate that the client is complying with client teaching? A. B. C. D. The client lies flat in the supine position for 12 hours The client continues oral fluids restriction while on bed rest The client’s family changed the dressing on return to the room The family activates the patient controlled analgesia pump 192. Which intervention should the nurse implement for the client who has and an ileal conduit? A. Pouch the stoma with a one (1) inch margin around the stoma B. Refer the client to the United Ostomy Association for discharge teaching C. Report to the health care provider any decrease in urinary output 40/53 D. Monitor the stoma for signs and symptoms of infection every shift 193. The nurse is preparing the plan of care for a client with fluid volume deficit. Which interventions should the nurse include in the plan of care? Select all that apply. A. B. C. D. E. Monitor vital signs every two (2) hours until stable Measure the client’s oral intake and urinary output daily Administer mouth care every eight (8) hours Weigh the client in the same clothing at the same time daily Assess skin turgor and mucous membranes every shift 194. Which outcome should the nurse identify for the client diagnosed with fluid volume excess? A. B. C. D. The client will void a minimum of 30 mL per hour The client will have elastic skin turgor The client will have no adventitious breath sounds The client will have a serum creatininie of 1.4 mg/dL 195. The nurse is caring for a client diagnosed with rule out nephritic syndrome. Which intervention should be included in the plan of care? A. B. C. D. Monitor the urine for bright-red-bleeding Evaluate the calorie count of the 500-mg protein diet Assess the client’s sacrum for dependant edema Monitor for a high serum albumin level 196. The nurse is preparing a teaching care plan for the client diagnosed with nephritic syndrome. Which intervention should the nurse include? A. B. C. D. Discontinue the use of steroids therapy immediately if symptoms develop. Take diuretics as needed to treat the dependant edema in ankles Increase the intake of dietary sodium every day to decrease fluid retention ‘ Report any decrease in daily weight during treatment to the HCP 197. Which intervention would be the most important for the nurse to implement for the client with a left nephrectomy? A. B. C. D. Asses the intravenous fluids for rate and volume Change surgical dressing every day at the same time Monitor the client’s medication levels daily Monitor the percentage of each meal eaten 41/53 198. The client has failed to conceive after many attempts over a three (3) year time period and asks the nurse. “I have tried everything. What should I do now?” Which statement is the nurse’s best response? A. B. C. D. Assess the intravenous fluids for rate and volume Change surgical dressing every day at the same time Monitor the client’s medication levels daily Monitor the percentage of each meal eaten 199. The nurse writes a problem of “potential for complication related to ovarian hypertstimulation “ for a client who is taking clomiphene (ClomiD., an ovarian stimulant. Which intervention should be included in the plan of care? A. B. C. D. Instruct the client to delay intercourse until menses Schedule the client for frequent pelvic sonograms Explain that the infusion therapy will take 21 days 2 Discuss that this may cause an ectopic pregnancy 200. The HCP care provider orders cultures of the urethral urine, bladder urine, and prostatic fluid. Which instructions would the nurse teach to achieve the first (2) specimens? A. B. C. D. Collect the first 15 mL in one jar and then the next 50 mL in another Collect three (3) early morning, clean voided urine specimens Collect the specimens after the HCP massages the prostate Collect a routine urine specimen for analysis 201. The nurse writes a client problem of “anxiety to potential sexual dysfunction” for a client diagnosed with cancer of the prostate. Which intervention should the nurse implement? A. B. C. D. Tell the client to discuss his fears with the HCP Talk to the wife about the client’s concerns Inform the client that sexual functioning will not be altered Provide a private area for the client to discuss his concerns 201. The male client is considering a vasectomy for birth control. Which information should the nurse teach the client? A. B. C. D. Instruct the client to use hot packs to relieve scrotal edema after the surgery Tell the client to wear loose-fitting boxer underwear after the surgery Explain that initially an alternate form of birth control will be required Discuss that potency will be diminished about 20% after a vasectomy 42/53 202. The 45 year old male client has had a circumcision secondary to phimosis. Which intervention should the nurse include in the plan of care? A. B. C. D. Teach how to care for the glands to prevent recurrence of the phimosis. Assess for pain on a scale of one (1) to ten (10) Perform wet to dry dressing changes daily Instruct client to perform a monthly penis check for cancer. 203. Which vaccination would the nurse recommend to the post pubertal male to preventorchitis? A. B. C. D. Yearly flu injections Herpes varicella inoculations Mumps vaccination Rubella injections 204. The nurse is instructing a group of workers at an industrial plant regarding the transmission of sexually transmitted diseases ( STDs). Which information should be included in the presentation? A. B. C. D. The same behaviors that cause one STD could lead to another Once clients have has an STD, they develop immunity to it. An infection with syphilis protects the client being infected with HIV. Herpes simplex I is a totally different disease from herpes simplex II. 205. When caring for a client with spica cast for a hip injury. What intervention should the nurse include in the plan of care? A. B. C. D. Assess client’s politeral pulses every shift Elevate the leg on pillows and apply ice packs Teach the client how to ambulate with a tripod walker Assess the client for distention and vomiting 206. When preparing the client in a short leg cast discharge, which data indicate that the client needs further teaching? A. B. C. D. “I need to keep my leg elevated on two pillows or the first 24 hours” “I should apply ice packs for one (1) hour and remove them for one (1) hour.” “I need to contact the health provider if I have any numbness or pale toenails.” “I can put a coat hanger down the cast to scratch gently if I have severe itching” 207. Which psychosocial client problem would be most likely in a client with an external fixator device? A. B. C. D. Ineffective coping Alteration in body image Grieving Social isolation 43/53 208. A client recovering from a total hip replacement has develop a deep vein thrombosis. The health care provider has ordered a continuous infusion of heparin, an anticoagulant, to infuse at 12000 units per hour. The bag comes with 20,000 units of heparin in 500 mL of 0.9% normal saline. At what rate should the nurse set the pump? 209. When conducting rounds at change of shift, the nurse assesses the client with a fractured humerus. What data would warrant immediate intervention by the nurse? A. B. C. D. Capillary refill time of that arm is less than three (3) seconds Pain relieved by the patient controlled anesthesia machine Edema under the dressing that caused the nails to be white Warm and dry skin on the fingers distally to the elastic bandage 210. The client with a right open fractured elbow has a long arm cast and is complaining of unrelenting severe pain and feeling as if the fingers are sleep. Which complications should the nurse suspect that the client is experiencing? A. B. C. D. Fat embolism Compartment syndrome Pressure ulcer cast Surgical infection 211. The elderly client is admitted to the hospital for severe back pain. Which data should the nurse assess first during the admission assessment? A. B. C. D. The client’s use of herbs The clients current pain level The client’s sexual orientation The client’s ability to care for itself 212. Which information should the nurse teach the client regarding sport injuries? A. B. C. D. Apply heat intermittently for the first 48 hours An injury is not serious if the extremity can be moved Only return to health care provider if the foot becomes cold Keep the injury immobilized and elevated for 24 to 48 hours 213. Which assessment technique should the nurse use to assess the client’s optic nerve? A. B. C. D. Have the client identify different smells Have the client discriminate between sugar and salt Have the client read the Smellen chart Have the client say “ hi” to assess the rise of the uvula 44/53 214. Which referral would be most important for the client with permanent hearing loss? A. B. C. D. Aural rehabilitation Speech therapist Social worker Vocational rehabilitation 215. Which instruction should the nurse discuss with the female client with viral conjunctivitis? A. B. C. D. Contact the HCP if pain occurs Do not share towels or linens Apply warm compresses to the eyes Apply makeup very lightly 216. The client is two (2) hours postoperative right-ear mastoidectomy. Which assessment data should be reported to the health care provider? A. B. C. D. Complaints of aural fullness Hearing loss in the affected ear No vertigo Facial dropping 217. Which behavior by the male client would make the nurse suspect the client has a hearing loss? Select all that apply. A. B. C. D. E. The client reports hearing voices in his head The client becomes irritable very easily The client has difficulty making decisions The client’s wife reports that he ignores her The client does not dominate a conversation 218. The client with cataracts who has had intraocular lens implants is being discharged from the day surgery department. Which discharge instructions should the nurse discuss with the client? A. B. C. D. Do not push or pull objects heavier than 50 pounds Lie on the affected eye with two pillows at night Wear glasses or metal eye shields at all times Bend and stoop carefully for the rest of your life 219. The nurse is assessing the client’s sensory system. Which result would indicate an abnormal stereogenosis test? A. The client is unable to identify which way the toe is being moved B. The client cannot discriminate between sharp and dull objects C. The toes contract and draw together when the sole of the foot is stroked 45/53 D. The client is unable to identify a key in the hand with both eyes closed 220. Which statement by the daughter of an 80 year old female client who lives alone would warrant immediate intervention by the nurse? A. B. C. D. “I put a night light in my mother’s bedroom.” “There are smoke alarms in every room.” “I changed my mother’s furniture around.” “I got my mother large-print books.” 221. The 72 year old client tells the nurse that food does not taste good anymore and that the has lost a little weight. Which information should the nurse discuss with the client? A. B. C. D. Suggest using extra seasoning when cooking Instruct the client to keep a seven (7) day food diary Refer the client to a dietitian immediately Recommend eating three meals a day 222. In children with meningitis, there is the potential for many complications occurring from damage to the nervous system. Which of the following is/are the most common, nonlethal complication(s)? A. B. C. D. Cranial nerve deficits Epilepsy Bleeding intracranially Cerebral palsy 223. A child is admitted to the nurse’s unit with a suspected diagnosis of meningitis. The nurse should tell the parent which of the following? A. Antibiotics are not initiated until the cerebrospinal fluid cultures are definitive for specificity to prevent resistance B. Antibiotics are useless against viral infections, so they are not used for meningitis C. Antibiotics should be started before the cerebrospinal fluid cultures are definitive because culture results may take up to 3 days D. Antibiotic initiation is based on the age, signs, symptoms of the patient, not on the causative agent 224. A child arrives at the pediatric emergency department, having had a generalized seizure at home and a recent sore throat and mild fever. During the nurse’s assessment, the child begins to have generalized tonic-clonic seizure activity. The drug of choice and method of administration the nurse expects the physician to order are which of the following? A. B. C. D. Lorezapram and diazepam, combined in an intravenous solution of D5W Lorezapram gives intravenously or diazepam given directly into a vein Phenobarbital administered In an intravenous solution of D5W, 0.45 normal saline Phenytoin in a dextrose solution given intravenously over 1 hour. 46/53 225.Parents of a child with generalized seizures ask the nurse for information to give their child’s teachers. Which of the following should be included? A. A soft-padded spoon should be kept nearby to put between the child’s teeth at the onset of a seizure. B. Roll the child onto the abdomen, with the head to the left, so any contents can flow from the mouth C. If a seizure lasts longer than 10 minutes, the parents or an ambulance should be called. D. As the child grows, medication dosages may need to be adjusted to control seizure activity 226. The nurse admitting a 5 month old who vomited 9 times in the past hours should observe for signs of which overall imbalance? A. B. C. D. Metabolic acidosis Metabolic alkalosis Some increase in the serum hemoglobin A little decrease in the serum potassium 227. A two year old child is brought to the provider’s office with a chief complaint of mild diarrhea for two days. Nutritional counseling by the nurse should include which statement? A. B. C. D. Place the child on clear liquids and gelatin for 24 hours Continue with the regular diet and include oral rehydration fluids Give bananas, apples, rice, and toast a tolerated Place NPO for 24 hours, then rehydrate with milk and water 228. The mother of a 3 month infant tells the nurse that she wants to change from formula to whole milk and add cereal and meats to the diet. What should be emphasized as the nurse teaches about infant nutrition? A. B. C. D. Solid foods should be introduced at 3-4 months Whole milk is difficult for a young infant to digest Fluoridated tap water should be used to dilute milk Supplemental apple juice can be used between feedings 229. The nurse is performing a physical assessment on a toddler. Which of the following actions should be the first? A. B. C. D. Perform traumatic procedures Use minimal physical contact Proceed from head to toe Explain the exam in detail 47/53 230. The nurse admits a 7 year old to the emergency room after a leg injury. The x-rays show a femur fracture near the epiphysis. The parents ask what will be the outcome of this injury. The appropriate response by the nurse should be which of these statements? A. B. C. D. “The injury is expected to heal quickly because of thin periosteum “In some instances the result is a retarded bone growth.” “Bone growth is stimulated in the affected leg.” “This type of injury shows more rapid union than that of younger children.” 231. Which of the following manifestation observed by the school nurse confirms the presence of pediculosiscapitis in students? A. B. C. D. Scratching the head more than usual Flakes evident on a student’s shoulders Oval pattern occipital hair loss Whitish oval specks sticking to the hair. 232. The mother of a 2 month old baby calls the nurse 2 days after the first DTap, IPV, Hepatitis B and HIB immunizations. She reports that the baby feels very warm, cries inconsolably for as long as 3 hours, and has had several shaking spells. In addition to referring her to the emergency room, the nurse should document the reaction on the baby’s record and expect which immunization to be most associated with the findings the infant is displaying? A. B. C. D. DTap Hepatitis B Polio H. Influenza 233. A 72 year old client with osteomyelitis requires a 6 week course of intravenous antibiotics. In planning for home care, what is the most important action by the nurse? A. B. C. D. Investigating the client’s insurance coverage for home IV antibiotic therapy Determining if there are adequate hand washing facilities in the home Assessing the client’s ability to participate in self-care and/or the ability of a care giver Selecting the appropriate venous access device 234. A nurse administers the influenza vaccine to a client in clinic. Within 15 minutes after immunization was given, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to A. B. C. D. Maintain the airway Administer epinephrine 1:1000 as ordered Monitor for hypotension with shock Administer diphenhydramine as ordered 48/53 235. The nurse instructs the client dexamethasone (Decadron) to take it with food or milk. The physiological basis for this instruction is that the medication A. B. C. D. Retards pepsin production Stimulates hydrochloric acid production Slows stomach emptying time Decreases production of hydrochloric acid 236. A client receiving chlorpromazine HCL ( ThorazinE is in psychiatric home care. During a home visit the nurse observed the client smacking her lips alternately with grinding her teeth. The nurse recognizes this assessment findings as what? A. B. C. D. Dystonia Akathisa Brady dyskinesia Tardive dyskinesia 237. Which of the following findings contraindicate the use of haloperidol (Inderal)and warrant with holding the dose? A. B. C. D. Drowsiness , lethargy, and inactivity Dry mouth, nasal congestion Rash, blood dyscrasis, severe depression Hyperglycemia, weight gain, and edema 238. A 42 year old male client refuses to take propranlol hydrochloride (Inderal) as prescribed. Which client statement from the assessment data is likely to explain his noncompliance ? A. B. C. D. “I have problems with diarrhea.” “I have difficulty failing asleep.” “I have diminished sexual function.” “I often feel jittery.” 239. A client who is former actress enters the day room wearing s sheer nightgown, high heels, numerous bracelets, bright red lipstick and heavily roughed cheeks. Which nursing action is best in response to the client’s attire? A. B. C. D. Gently remind her that she is no longer on stage Directly assist client to her room for appropriate apparel Quietly point out to her the dress of other clients on the unit Tactfully explain appropriate clothing for the hospital 240. Which of the following times is a depressed client at highest risk for attempting suicide? A. Immediately after admission, during one to one observation B. 7 to 14 days after initiation of antidepressant medication and psychotherapy 49/53 C. Following an angry outburst with family D. When the client is removed from the security room 241. The nurse provides discharge teaching to the parents of a 15 month old child with Kawasaki disease. The child has receive immunoglobulin therapy. Which instruction would be appropriate? A. B. C. D. High dose of aspirin will be continued for some time. Complete recovery is expected within several days Active range of motion exercise should be done frequently The measles, mumps and rubella vaccine should be delayed 242. A 10 year old client is recovering from a splecnectomy following a traumatic injury. The clients laboratory results ahemoglobin of 9 g/dL and a hematocrit of 28 percent. The best approach for the nurse to use it to A. B. C. D. Limit milk and milk products Encourage bed activities and games Plan nursing care around lengthy rest periods promote a diet rich in iron 243. The nurse is planning care for a 14 year old client returning from scoliosis corrective surgery. Which of the following actions should receive priority in the plan? A. B. C. D. Antibiotic therapy for 10 days Teach client isometric exercises for legs Assess movement and sensation of extremities Assist to stand up at bedside within first 24 hours 244. The nurse is caring for a 17 month old with acetaminophen poisoning. Which of the following lab reports should the nurse review first? A. B. C. D. Prothrombin Time (PT) and partial thrombosplatin time (PTT) Red blood cell and white cell counts Blood urea nitrogen and creatinine clearance Liver enzyme (AST and ALT) 245. A 6 year old child is seen for the first time in the clinic. Upon assessment, nurse finds that the child has deformities of the joints, limbs, and fingers, thinned upper lip, and small teeth with faulty enamel. The mother states: “My child seems to have problems is learning to count and recognizing basic colors.” Based on this data, the nurse suspects that the child is most likely showing the effects of which problem? A. B. C. D. Congenital abnormalities Chronic toxoplasmosis’ Fetal alcohol syndrome (FAS) Lead poisoning 50/53 246. The nurse is caring for a client with distal tibia fracture. The client has had a closed reduction and application of a toe to groin cast. 36 hours after surgery, the client suddenly becomes confused, short of breath and spikes a temperature of 103 degrees F. The first assessment the nurse should perform is A. B. C. D. Orientation to time, place and person Pulse oximetry Circulation to casted extremities Blood pressure 247. A client diagnosed with hepatitis C discusses his health history with the admitting nurse. The nurse should recognize which statement by the client as the most important? A. B. C. D. I got back from Central America a few weeks ago. I had the best raw oysters last week I have many different sex partners I had a blood transfusion 15 years ago 248. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse implement first? A. B. C. D. Institute seizure precautions Monitor neurologic status every hour Place in respiratory/secretion precautions Cefotaxime IV 50 mg/kg/day divided q6h 249. A client is scheduled to receive an oral solution of radioactive iodine (1311). In order to reduce hazards, the priority information for the nurse to include in client teaching is which of these statements? A. “In the initial 48 hours, avoid contact with children and pregnant women, and flush the commode twice after urination or defection.” B. “Use disposable utensils for 2 days and if vomiting occurs with 10 hours of the dose, do so in the toilet and flush it twice.” C. “Your family can use the same bathroom that you use with out any special precautions.” D. “Drink plenty of water and empty your bladder often during the initial 3 days of therapy.” 250. The school nurse is teaching the faculty is the most effective methods to prevent the spread of lice (Pediculus250. The school nurse is teaching the faculty the most effective methods to prevent the spread of lice (pediculus Humanus Capitis) in the school. The information that would be most important to include is reflected in which of these statements? A. “The treatment medication requires reapplication in 8 to 10 days.” B. “Bedding and clothing can be boiled or steamed to kill lice.” C. “Children should not share hats, scarves, and combs.” D. “Nit combs are necessary to comb lice eggs (nits) out of the children’s hair.” 51/53