1101. The nurse is caring for a client post-op femoral popliteal
bypass graft. Which post-operative assessment finding would require
immediate physician notification?
A. Edema of the extremity and pain at the incision site
B. A temperature of 99.6°F and redness of the incision
C. Serous drainage noted at the surgical area
D. A loss of posterior tibial and dorsalis pedis pulses
A. Edema of the extremity and pain at the incision site
B. A temperature of 99.6°F and redness of the incision
C. Serous drainage noted at the surgical area
D. A loss of posterior tibial and dorsalis pedis pulses
1102.
A client admitted with gastroenteritis and a potassium level of
2.9mEq/dL has been placed on telemetry. Which ECG finding would the
nurse expect to find due to the client’s potassium results?
A. A depressed ST segment
B. An elevated T wave
C. An absent P wave
D. A flattened QRS
A. A depressed ST segment
B. An elevated T wave
C. An absent P wave
D. A flattened QRS
1103.
A client is experiencing acute abdominal pain. Which abdominal
assessment sequence is appropriate for the nurse to use for examination
of the abdomen?
A. Inspect, palpate, auscultate, percuss
B. Inspect, auscultate, percuss, palpate
C. Auscultate, inspect, palpate, percuss
D. Percuss, palpate, auscultate, inspect
A. Inspect, palpate, auscultate, percuss
B. Inspect, auscultate, percuss, palpate
C. Auscultate, inspect, palpate, percuss
D. Percuss, palpate, auscultate, inspect
1104.
The nurse is to administer a cleansing enema to a client scheduled for
colon surgery. Which client position would be appropriate?
A. Prone
B. Supine
C. Left Sim’s
D. Dorsal recumbent
A. Prone
B. Supine
C. Left Sim’s
D. Dorsal recumbent
1105.
The nurse is caring for a client following a crushing injury to the
chest. Which finding would be most indicative of a tension pneumothorax?
A. Expectoration of moderate amounts of frothy hemoptysis
B. Trachea shift toward the unaffected side of the chest
C. Subcutaneous emphysema noted at the anterior chest
D. Opening chest wound with a whistle sound emitting from the area
A. Expectoration of moderate amounts of frothy hemoptysis
B. Trachea shift toward the unaffected side of the chest
C. Subcutaneous emphysema noted at the anterior chest
D. Opening chest wound with a whistle sound emitting from the area
1106.
The nurse receives a report from the paramedic on four trauma victims.
Which client would need to be treated first? A client with:
A. Lower rib fractures and a stable chest wall
B. Bruising on the anterior chest wall and a possible pulmonary contusion
C. Gun shot wound with open pneumothorax unstabilized
D. Dyspnea, stabilized with intubation and manual resuscitator
A. Lower rib fractures and a stable chest wall
B. Bruising on the anterior chest wall and a possible pulmonary contusion
C. Gun shot wound with open pneumothorax unstabilized
D. Dyspnea, stabilized with intubation and manual resuscitator
1107.
The nurse is discharging a client with asthma who has a prescription
for zafirlukast (Accolate). Which comment by the client would indicate a
need for further teaching?
A. “I should take this medication with meals.”
B. “I need to report flu-like symptoms to my doctor.”
C. “My doctor might order liver tests while I’m on this drug.”
D. “If I’m already having an asthma attack, this drug will not stop it.”
A. “I should take this medication with meals.”
B. “I need to report flu-like symptoms to my doctor.”
C. “My doctor might order liver tests while I’m on this drug.”
D. “If I’m already having an asthma attack, this drug will not stop it.”
1108.
A client is four hours post-op left carotid endarterectomy. Which
assessment finding would cause the nurse the most concern?
A. Temperature 99.4°F, heart rate 110, respiratory rate 24
B. Drowsiness, urinary output of 50mL in the past hour
C. BP 120/60, lethargic, right-sided weakness
D. Alert and oriented, BP 168/96, heart rate 70
A. Temperature 99.4°F, heart rate 110, respiratory rate 24
B. Drowsiness, urinary output of 50mL in the past hour
C. BP 120/60, lethargic, right-sided weakness
D. Alert and oriented, BP 168/96, heart rate 70
1109.
The RN is making assignments on a 12-bed unit. Staff consists of one RN
and two certified nursing assistants. Which client should be
self-assigned?
A. A client receiving decadron for emphysema
B. A client with chest trauma and a new onset of hemoptysis
C. A client with rib fractures and an O2 saturation of 93%
D. A client two days post-operative lung surgery with a pulse oximetry of 92%
A. A client receiving decadron for emphysema
B. A client with chest trauma and a new onset of hemoptysis
C. A client with rib fractures and an O2 saturation of 93%
D. A client two days post-operative lung surgery with a pulse oximetry of 92%
1110.
The nurse is accessing a venous access port of a client about to
receive chemotherapy. Place the following steps in proper sequential
order:
I. Apply clean gloves.
II. Clean the skin with antimicrobial and let air dry.
III. Insert needle into port at a 90° angle.
IV. Connect 10mL NS into extension of huber needle and prime.
V. Instill heparin solution.
VI. Stabilize the part by using middle and index fingers.
VII. Wash hands and apply sterile gloves.
VIII. Inject saline and assess for infiltration.
IX. Check placement of needle.
A. I, IV, II, VII, IX, III, VI, VIII, V
B. I, III, IV, VII, VI, II, IX, VIII, V
C. I, II, IV, V, VI, III, IX, VIII, VII
D. I, II, IV, VII, VI, III, IX, VIII, V
I. Apply clean gloves.
II. Clean the skin with antimicrobial and let air dry.
III. Insert needle into port at a 90° angle.
IV. Connect 10mL NS into extension of huber needle and prime.
V. Instill heparin solution.
VI. Stabilize the part by using middle and index fingers.
VII. Wash hands and apply sterile gloves.
VIII. Inject saline and assess for infiltration.
IX. Check placement of needle.
A. I, IV, II, VII, IX, III, VI, VIII, V
B. I, III, IV, VII, VI, II, IX, VIII, V
C. I, II, IV, V, VI, III, IX, VIII, VII
D. I, II, IV, VII, VI, III, IX, VIII, V
1111.
A client is being discharged on Coumadin after hospitalization for a
deep vein thrombosis. The nurse recognizes that which food would be
restricted while the client is on this medication?
A. Lettuce
B. Apples
C. Potatoes
D. Macaroni
A. Lettuce
B. Apples
C. Potatoes
D. Macaroni
1112. Which assessment finding in a client with COPD indicates to the nurse that the respiratory problem is chronic?
A. Wheezing on exhalation
B. Productive cough
C. Clubbing of fingers
D. Generalized cyanosis
A. Wheezing on exhalation
B. Productive cough
C. Clubbing of fingers
D. Generalized cyanosis
1113.
A client who has just undergone a laparoscopic cholecystectomy
complains of “free air pain.” What would be your best action?
A. Ambulate the client.
B. Instruct the client to breathe deeply and cough.
C. Maintain the client on bed rest with his legs elevated.
D. Insert an NG tube.
A. Ambulate the client.
B. Instruct the client to breathe deeply and cough.
C. Maintain the client on bed rest with his legs elevated.
D. Insert an NG tube.
1114. The RN is planning client assignments. Which is the least appropriate task for the nursing assistant?
A. Assisting a COPD client admitted two days ago to get up in the chair.
B. Feeding a client with bronchitis who is paralyzed on the right side.
C. Accompanying a discharged emphysema client to the transportation area.
D. Assessing an emphysema client complaining of difficulty breathing.
A. Assisting a COPD client admitted two days ago to get up in the chair.
B. Feeding a client with bronchitis who is paralyzed on the right side.
C. Accompanying a discharged emphysema client to the transportation area.
D. Assessing an emphysema client complaining of difficulty breathing.
1115. When providing care for a client with pancreatitis, the nurse would anticipate which of the following orders?
A. Force fluids to 3,000mL/24 hours.
B. Insert a nasogastric tube to low intermittent suction.
C. Place the client in reverse Trendelenburg position.
D. Place the client in enteric isolation.
A. Force fluids to 3,000mL/24 hours.
B. Insert a nasogastric tube to low intermittent suction.
C. Place the client in reverse Trendelenburg position.
D. Place the client in enteric isolation.
1116.
The nurse is performing a neurological assessment on a client admitted
with TIAs. Assessment findings reveal an absence of the gag reflex. The
nurse suspects injury to which of the following cranial nerves?
A. XII (hypoglossal)
B. X (vagus)
C. IX (glossopharyngeal)
D. VII (facial)
A. XII (hypoglossal)
B. X (vagus)
C. IX (glossopharyngeal)
D. VII (facial)
1117.
The nurse has been asked to present a lecture on the prevention of West
Nile virus in the community setting. Which does the nurse include in
the teaching plan?
A. Wear protective clothing outside.
B. Avoid being outside in the middle of the day.
C. Avoid the use of insect repellant containing DEET.
D. The virus is more prevalent in people under 18 years old.
A. Wear protective clothing outside.
B. Avoid being outside in the middle of the day.
C. Avoid the use of insect repellant containing DEET.
D. The virus is more prevalent in people under 18 years old.
1118.
A client with gallstones and obstructive jaundice is experiencing
severe itching. The physician has prescribed cholestyramine (Questran).
The client asks, “How does this drug work?” What is the nurse’s best
response?
A. “It blocks histamine, reducing the allergic response.”
B. “It inhibits the enzyme responsible for bile excretion.”
C. “It decreases the amount of bile in the gallbladder.”
D. “It binds with bile acids and is excreted in bowel movements with stool.”
A. “It blocks histamine, reducing the allergic response.”
B. “It inhibits the enzyme responsible for bile excretion.”
C. “It decreases the amount of bile in the gallbladder.”
D. “It binds with bile acids and is excreted in bowel movements with stool.”
1119.
A client with inflammatory bowel disease (IBD) requires an ileostomy.
The nurse would instruct the client to do which of the following
measures as an essential part of caring for the stoma?
A. Perform massage of the stoma three times a day.
B. Include high-fiber foods in the diet, especially nuts.
C. Limit fluid intake to prevent loose stools.
D. Cleanse the peristomal skin meticulously.
A. Perform massage of the stoma three times a day.
B. Include high-fiber foods in the diet, especially nuts.
C. Limit fluid intake to prevent loose stools.
D. Cleanse the peristomal skin meticulously.
1120.
Diphenoxylate hydrochloride and atropine sulfate (Lomotil) is
prescribed for the client with ulcerative colitis. Which of the
following nursing observations indicates that the drug is having a
therapeutic effect?
A. There is an absence of peristalsis.
B. The number of diarrhea stools decreases.
C. Cramping in the abdomen has increased.
D. Abdominal girth size increases.
A. There is an absence of peristalsis.
B. The number of diarrhea stools decreases.
C. Cramping in the abdomen has increased.
D. Abdominal girth size increases.
1121.
A nurse is assisting the physician with chest tube removal. Which
client instruction is appropriate during removal of the tube?
A. Take a deep breath or hum during removal.
B. Hold the breath for two minutes and exhale slowly.
C. Exhale upon actual removal of the tube.
D. Continually breathe deeply in and out during removal.
A. Take a deep breath or hum during removal.
B. Hold the breath for two minutes and exhale slowly.
C. Exhale upon actual removal of the tube.
D. Continually breathe deeply in and out during removal.
1122.
A client with advanced Alzheimer’s disease has been prescribed
haloperidol (Haldol). What clinical manifestation suggests that the
client is experiencing side effects from this medication?
A. Cough
B. Tremors
C. Diarrhea
D. Pitting edema
A. Cough
B. Tremors
C. Diarrhea
D. Pitting edema
1123.
A student in a cardiac unit is performing auscultation of a client’s
heart. Which stethoscope placement would indicate to the nurse that the
student is performing pulmonic auscultation correctly?
A. Between the apex and the sternum
B. At the fifth intercostal space at the left midclavicular line
C. At the second intercostal space, left of the sternum
D. At the manubrium area of the chest
A. Between the apex and the sternum
B. At the fifth intercostal space at the left midclavicular line
C. At the second intercostal space, left of the sternum
D. At the manubrium area of the chest
1124.
A client with Alzheimer’s disease has been prescribed donepezil
(Aricept). Which information should the nurse include in the teaching
plan for a client on Aricept?
A. “Take the medication with meals.”
B. “The medicine can cause dizziness, so rise slowly.”
C. “If a dose is skipped, take two the next time.”
D. “The pill can cause an increase in heart rate.”
A. “Take the medication with meals.”
B. “The medicine can cause dizziness, so rise slowly.”
C. “If a dose is skipped, take two the next time.”
D. “The pill can cause an increase in heart rate.”
1125.
A client who had major abdominal surgery is having delayed healing of
the wound. Which laboratory test result would most closely correlate
with this problem?
A. Decreased albumin
B. Decreased creatinine
C. Increased calcium
D. Increased sodium
A. Decreased albumin
B. Decreased creatinine
C. Increased calcium
D. Increased sodium
1126.
A client is admitted to the medical-surgical unit with a report of
severe hematemesis. What is the priority nursing action?
A. Performing an assessment
B. Obtaining a blood permit
C. Initiating an IV
D. Inserting an NG tube
A. Performing an assessment
B. Obtaining a blood permit
C. Initiating an IV
D. Inserting an NG tube
1127.
The nurse caring for a client with a suspected peptic ulcer recognizes
which exam as the one most reliable in diagnosing the disease?
A. Upper-gastrointestinal x-ray
B. Gastric analysis
C. Endoscopy procedure
D. Barium studies x-ray
A. Upper-gastrointestinal x-ray
B. Gastric analysis
C. Endoscopy procedure
D. Barium studies x-ray
1128.
On the second post-operative day after a subtotal thyroidectomy, the
client tells the nurse, “I feel numbness and my face is twitching.” What
is the nurse’s best initial action?
A. Offer mouth care.
B. Loosen the neck dressing.
C. Notify the physician.
D. Document the finding as the only action.
A. Offer mouth care.
B. Loosen the neck dressing.
C. Notify the physician.
D. Document the finding as the only action.
1129.
A client with adult respiratory distress syndrome has been placed on
mechanical ventilation with PEEP. Which finding would indicate to the
nurse that the client is experiencing the undesirable effect of an
increase in airway and chest pressure?
A. A PO2 of 88
B. Rales on auscultation
C. Blood pressure decrease to 90/48 from 120/70
D. A decrease in spontaneous respirations
A. A PO2 of 88
B. Rales on auscultation
C. Blood pressure decrease to 90/48 from 120/70
D. A decrease in spontaneous respirations
1130.
A nurse is teaching a group of teenagers the correct technique for
applying a condom. Which point would the nurse include in the teaching
plan?
A. The condom can be reused one time.
B. Unroll the condom all the way over the erect penis.
C. Apply petroleum jelly to reduce irritation.
D. Place water in the tip of the condom before use.
A. The condom can be reused one time.
B. Unroll the condom all the way over the erect penis.
C. Apply petroleum jelly to reduce irritation.
D. Place water in the tip of the condom before use.
1131.
A client with rheumatoid arthritis is being discharged with a
prescription for etanercept (Enbrel). Which should the nurse teach the
client to report immediately?
A. Redness, itching, edema at injection site
B. Exposure to chickenpox or shingles
C. Headache
D. Vomiting
A. Redness, itching, edema at injection site
B. Exposure to chickenpox or shingles
C. Headache
D. Vomiting
1132.
The nurse in the ER has received report of four clients en route to the
emergency department. Which client should the nurse see first? A client
with:
A. Third-degree burns to the face and neck area, with singed nasal hairs
B. Second-degree burns to each leg and thigh area, who is alert and oriented
C. A chemical burn that has been removed and liberally flushed before admission
D. An electrical burn entering and leaving on the same side of the body
A. Third-degree burns to the face and neck area, with singed nasal hairs
B. Second-degree burns to each leg and thigh area, who is alert and oriented
C. A chemical burn that has been removed and liberally flushed before admission
D. An electrical burn entering and leaving on the same side of the body
1133. Which clinical manifestations would the nurse expect a client with a diagnosis of acute osteomyelitis to exhibit?
Select all that apply.
I. Normal sedimentation rate
II. Pain and fever
III. Low blood count
IV. Tenderness in affected area
V. Edema and pus from the wound
A. I, III and V
B. V only
C. II, III and V
D. II, IV, and V
Select all that apply.
I. Normal sedimentation rate
II. Pain and fever
III. Low blood count
IV. Tenderness in affected area
V. Edema and pus from the wound
A. I, III and V
B. V only
C. II, III and V
D. II, IV, and V
1134. The nurse recognizes which of the following clients as having the highest risk for pulmonary complications after surgery?
A. A 24-year-old with open reduction internal fixation of the ulnar
B. A 45-year-old with an open cholecystectomy
C. A 36-year-old after a hysterectomy
D. A 50-year-old after a lumbar laminectomy
A. A 24-year-old with open reduction internal fixation of the ulnar
B. A 45-year-old with an open cholecystectomy
C. A 36-year-old after a hysterectomy
D. A 50-year-old after a lumbar laminectomy
1135. Which clinical manifestation is most indicative to the nurse that a possible carbon monoxide poisoning has occurred?
A. Pulse oximetry reading of 80%
B. Expiratory stridor and nasal flaring
C. Cherry red color to the mucous membranes
D. Presence of carbonaceous particles in the sputum
A. Pulse oximetry reading of 80%
B. Expiratory stridor and nasal flaring
C. Cherry red color to the mucous membranes
D. Presence of carbonaceous particles in the sputum
1136.
A client is admitted with a ruptured spleen following a four-wheeler
accident. In preparation for surgery, the nurse suspects that the client
is in the compensatory stage of shock because of which clinical
manifestation?
A. Blood pressure 120/70, confusion, heart rate 120
B. Crackles on chest auscultation, mottled skin, lethargy
C. Jaundice, urine output less than 30mL in the past hour, heart rate 170
D. Rapid shallow respirations, unconscious, petechiae anterior chest
A. Blood pressure 120/70, confusion, heart rate 120
B. Crackles on chest auscultation, mottled skin, lethargy
C. Jaundice, urine output less than 30mL in the past hour, heart rate 170
D. Rapid shallow respirations, unconscious, petechiae anterior chest
1137.
A client reports to the nurse that he believes he has an ulcer and
wants to be checked for H. pylori. Which of the following medications in
the client’s history could make the test invalid?
A. Omeprazole (Prilosec)
B. Furosemide (Lasix)
C. Propoxyphene napsylate (Darvocet)
D. Ibuprofen (Advil)
A. Omeprazole (Prilosec)
B. Furosemide (Lasix)
C. Propoxyphene napsylate (Darvocet)
D. Ibuprofen (Advil)
1138.
A client arrives in the emergency room with severe burns of the hands,
right arm, face, and neck. The nurse needs to start an IV. Which site
would be most suitable for this client?
A. Top of client’s right hand
B. Left antecubital fossa
C. Top of either foot
D. Left forearm
A. Top of client’s right hand
B. Left antecubital fossa
C. Top of either foot
D. Left forearm
1139.
Which client clinical manifestation during a bone marrow
transplantation procedure alerts the nurse to the possibility of an
adverse reaction?
A. Fever
B. Red colored urine
C. Hypertension
D. Shortness of breath
A. Fever
B. Red colored urine
C. Hypertension
D. Shortness of breath
1140.
The nurse is assessing the integumentary system of a dark-skinned
individual. Which area would be the most likely to show a skin cancer
lesion?
A. Chest
B. Arms
C. Face
D. Palms
A. Chest
B. Arms
C. Face
D. Palms
1141.
A client with a gastrointestinal bleed has an NG tube to low continuous
wall suction. Which technique is the correct procedure for the nurse to
utilize when assessing bowel sounds?
A. Obtain a sample of the NG drainage and test the pH.
B. Clamp the tube while listening to the abdomen with a stethoscope.
C. Irrigate the tube with 30mL of NS while auscultating the abdomen.
D. Turn the suction on high and auscultate over the naval area.
A. Obtain a sample of the NG drainage and test the pH.
B. Clamp the tube while listening to the abdomen with a stethoscope.
C. Irrigate the tube with 30mL of NS while auscultating the abdomen.
D. Turn the suction on high and auscultate over the naval area.
1142.
A burn client’s care plan reveals an expected outcome of no localized
or systemic infection. Which assessment by the nurse supports this
outcome?
A. Wound culture results showing minimal bacteria
B. Cloudy, foul-smelling urine
C. White blood cell count of 14,000/mm3
D. Temperature elevation of 101°F
A. Wound culture results showing minimal bacteria
B. Cloudy, foul-smelling urine
C. White blood cell count of 14,000/mm3
D. Temperature elevation of 101°F
1143.
The nurse is discharging a client with a prescription of eyedrops.
Which observation by the nurse would indicate a need for further client
teaching?
A. Shaking of the suspension to mix the medication
B. Administering a second eyedrop medication immediately after the first one was instilled
C. Washing the hands before and after the administration of the drops
D. Holding the lower lid down without pressing the eyeball to instill the drops
A. Shaking of the suspension to mix the medication
B. Administering a second eyedrop medication immediately after the first one was instilled
C. Washing the hands before and after the administration of the drops
D. Holding the lower lid down without pressing the eyeball to instill the drops
1144.
The nurse is caring for a client with pneumonia who is allergic to
penicillin. Which antibiotic is safest to administer to this client?
A. Cefazolin (Ancef)
B. Amoxicillin
C. Erythrocin (Erythromycin)
D. Ceftriaxone (Rocephin)
A. Cefazolin (Ancef)
B. Amoxicillin
C. Erythrocin (Erythromycin)
D. Ceftriaxone (Rocephin)
1145.
The nurse notes the following laboratory test results on a 24-hour
post-burn client. Which abnormality should be reported to the physician
immediately?
A. Potassium 7.5mEq/L
B. Sodium 131mEq/L
C. Arterial pH 7.34
D. Hematocrit 52%
A. Potassium 7.5mEq/L
B. Sodium 131mEq/L
C. Arterial pH 7.34
D. Hematocrit 52%
1146.
The nurse is observing a student nurse administering ear drops to a
two-year-old. Which observation by the nurse would indicate correct
technique?
A. Holds the child’s head up and extended
B. Places the head in chin-tuck position
C. Pulls the pinna down and back
D. Irrigates the ear before administering medication
A. Holds the child’s head up and extended
B. Places the head in chin-tuck position
C. Pulls the pinna down and back
D. Irrigates the ear before administering medication
1147.
The nurse is caring for a client with scalding burns across the face,
neck, upper half of the anterior chest, and entire right arm. Using the
rule of nines, estimate the percentage of body burned.
A. 18%
B. 23%
C. 32%
D. 36%
A. 18%
B. 23%
C. 32%
D. 36%
1148.
The nurse caring for a client in shock recognizes that the glomerular
filtration rate of the kidneys will fail if the client’s mean arterial
pressure falls below which of the following levels?
A. 140
B. 120
C. 100
D. 80
A. 140
B. 120
C. 100
D. 80
1149.
The nurse is caring for a child with a diagnosis of possible
hydrocephalus. Which assessment data on the admission history would be
the most objective?
A. Anorexia
B. Vomiting
C. Head measurement
D. Temperature reading
A. Anorexia
B. Vomiting
C. Head measurement
D. Temperature reading
1150.
A client is admitted after a motor vehicle accident. Based on the
following results, what physician’s prescription will the nurse
anticipate?
A. Blood transfusion
B. Potassium IVPB
C. Mechanical ventilator
D. Platelet transfusion
A. Blood transfusion
B. Potassium IVPB
C. Mechanical ventilator
D. Platelet transfusion
1151.
The nurse is caring for a client after a burn. Which assessment finding
best indicates that the client’s respiratory efforts are currently
adequate?
A. The client is able to talk.
B. The client is alert and oriented.
C. The client’s O2 saturation is 97%.
D. The client’s chest movements are uninhibited.
A. The client is able to talk.
B. The client is alert and oriented.
C. The client’s O2 saturation is 97%.
D. The client’s chest movements are uninhibited.
1152.
The nurse is performing discharge teaching to the parents of a
seven-year-old who has been diagnosed with asthma. Which sports activity
would be most appropriate for this client?
A. Baseball
B. Swimming
C. Football
D. Track
A. Baseball
B. Swimming
C. Football
D. Track
1153. The leukemic client is prescribed a low-bacteria diet. Which does the nurse expect to be included in this diet?
A. Cooked spinach and sautéed celery
B. Lettuce and alfalfa sprouts
C. Fresh strawberries and whipped cream
D. Raw cauliflower or broccoli
A. Cooked spinach and sautéed celery
B. Lettuce and alfalfa sprouts
C. Fresh strawberries and whipped cream
D. Raw cauliflower or broccoli
1154.
A child is to receive heparin sodium five units per kilogram of body
weight by subcutaneous route every four hours. The child weighs 52.8 lb.
How many units should the child receive in a 24-hour period?
A. 300
B. 480
C. 720
D. 960
A. 300
B. 480
C. 720
D. 960
1155.
A client with cancer is experiencing a common side effect of
chemotherapy administration. Which laboratory assessment finding would
cause the most concern?
A. A sodium level of 50mg/dL
B. A blood glucose of 110mg/dL
C. A platelet count of 125,000/mm3
D. A white cell count of 5,000/mm3
A. A sodium level of 50mg/dL
B. A blood glucose of 110mg/dL
C. A platelet count of 125,000/mm3
D. A white cell count of 5,000/mm3
1156.
A client’s admission history reveals complaints of fatigue, chronic
sore throat, and enlarged lymph nodes in the axilla and neck. Which exam
would assist the physician to make a tentative diagnosis of leukemia?
A. A complete blood count
B. An x-ray of the chest
C. A bone marrow aspiration
D. A CT scan of the abdomen
A. A complete blood count
B. An x-ray of the chest
C. A bone marrow aspiration
D. A CT scan of the abdomen
1157.
A client is admitted with symptoms of vertigo and syncope. Diagnostic
tests indicate left subclavian artery obstruction. What additional
findings would the nurse expect?
A. Memory loss and disorientation
B. Numbness in the face, mouth, and tongue
C. Radial pulse differences over 10bpm
D. Frontal headache with associated nausea or emesis
A. Memory loss and disorientation
B. Numbness in the face, mouth, and tongue
C. Radial pulse differences over 10bpm
D. Frontal headache with associated nausea or emesis
1158.
The nurse is performing discharge teaching on a client at high risk for
the development of skin cancer. Which instruction should be included in
the client teaching?
A. “You should see the doctor every six months.”
B. “Sunbathing should be done between the hours of noon and 3 p.m.”
C. “If you have a mole, it should be removed and biopsied.”
D. “You should wear sunscreen when going outside.”
A. “You should see the doctor every six months.”
B. “Sunbathing should be done between the hours of noon and 3 p.m.”
C. “If you have a mole, it should be removed and biopsied.”
D. “You should wear sunscreen when going outside.”
1159.
The nurse is caring for a client with pancreatitis has been transferred
to the intensive care unit. The nurse assesses a pulmonary arterial
wedge pressure (PAWP) of 14mmHg. Based on this finding, the nurse would
want to further assess for what additional correlating wedge pressure
data?
A. A drop in blood pressure
B. Rales on chest auscultation
C. A temperature elevation
D. Dry mucous membranes
A. A drop in blood pressure
B. Rales on chest auscultation
C. A temperature elevation
D. Dry mucous membranes
1160.
The nurse is caring for a client with a diagnosis of hepatitis who is
experiencing pruritis. Which would be the most appropriate nursing
intervention?
A. Suggest that the client take warm showers.
B. Add baby oil to the client’s bath water.
C. Apply powder to the client’s skin.
D. Suggest a hot-water rinse after bathing.
A. Suggest that the client take warm showers.
B. Add baby oil to the client’s bath water.
C. Apply powder to the client’s skin.
D. Suggest a hot-water rinse after bathing.
1161.
A client is admitted to the emergency department with a loss of
consciousness with unknown etiology. The nurse expects to perform which
laboratory test to assist in determining etiology?
A. Total cholesterol
B. Alkaline phosphatese
C. Serum glucose
D. Urinalysis
A. Total cholesterol
B. Alkaline phosphatese
C. Serum glucose
D. Urinalysis
1162.
The physician has ordered a homocysteine blood level on a client. The
nurse recognizes that the results will be increased in a client with a
deficiency in which of the following:
A. Vitamin B12
B. Vitamin C
C. Vitamin A
D. Vitamin E
A. Vitamin B12
B. Vitamin C
C. Vitamin A
D. Vitamin E
1163. The registered nurse is assigning staff for four clients on the 3–11 shift. Which client should be assigned to the LPN?
A. A client with a diagnosis of adult respiratory distress syndrome (ARDS) who was transferred from the critical care unit at 1400
B. A one-hour post-operative colon resection
C. A client with pneumonia expecting discharge in the morning
D. A client with cirrhosis of the liver experiencing bleeding from esophageal varices
A. A client with a diagnosis of adult respiratory distress syndrome (ARDS) who was transferred from the critical care unit at 1400
B. A one-hour post-operative colon resection
C. A client with pneumonia expecting discharge in the morning
D. A client with cirrhosis of the liver experiencing bleeding from esophageal varices
1164.
A client with multiple sclerosis has an order to receive Solu Medrol
200mg IV push. The available dose is Solu Medrol 250mg per mL. How much
medication will the nurse administer?
A. 0.5 mL
B. 0.8 mL
C. 1.1 mL
D. 1.4 mL
A. 0.5 mL
B. 0.8 mL
C. 1.1 mL
D. 1.4 mL
1165.
The nurse is obtaining a history on a 74-year-old client. Which
statement made by the client would most alert the nurse to a possible
fluid and electrolyte imbalance?
A. “My skin is always so dry.”
B. “I often use a laxative for constipation.”
C. “I have always liked to drink a lot of water.”
D. “I sometimes have a problem with dribbling urine.”
A. “My skin is always so dry.”
B. “I often use a laxative for constipation.”
C. “I have always liked to drink a lot of water.”
D. “I sometimes have a problem with dribbling urine.”
1166.
The nurse is caring for a client in the acute care unit. Initial
laboratory values reveal serum sodium of 156mEq/L. What behavior changes
would the nurse expect the client to exhibit?
A. Hyporeflexia
B. Manic behavior
C. Depression
D. Muscle cramps
A. Hyporeflexia
B. Manic behavior
C. Depression
D. Muscle cramps
1167.
The nurse is completing the preoperative checklist on a client
scheduled for surgery and finds that the consent form has been signed,
but the client is unclear about the surgery and possible complications.
Which is the most appropriate action?
A. Call the surgeon and ask him to come see the client to clarify the information.
B. Explain the procedure and complications to the client.
C. Check in the physician’s progress notes to see if understanding has been documented.
D. Check with the client’s family to see if they understand the procedure fully.
A. Call the surgeon and ask him to come see the client to clarify the information.
B. Explain the procedure and complications to the client.
C. Check in the physician’s progress notes to see if understanding has been documented.
D. Check with the client’s family to see if they understand the procedure fully.
1168.
When preparing a client for admission to the surgical suite, the nurse
recognizes that which one of the following items is most important to
remove before sending the client to surgery?
A. Hearing aid
B. Contact lenses
C. Wedding ring
D. Dentures
A. Hearing aid
B. Contact lenses
C. Wedding ring
D. Dentures
1169. A client with cancer is to undergo a bone scan. The nurse should perform which of the following actions?
A. Force fluids 24 hours before the procedure is scheduled to begin.
B. Ask the client to void immediately before the study.
C. Hold medication that affects the central nervous system for 12 hours pre- and post-test.
D. Cover the client’s reproductive organs with an x-ray shield during the procedure.
A. Force fluids 24 hours before the procedure is scheduled to begin.
B. Ask the client to void immediately before the study.
C. Hold medication that affects the central nervous system for 12 hours pre- and post-test.
D. Cover the client’s reproductive organs with an x-ray shield during the procedure.
1170.
A client with suspected leukemia is to undergo a bone marrow
aspiration. The nurse plans to include which statement in the teaching
session?
A. “You will be lying on your abdomen for the examination procedure.”
B. “Portions of the procedure will cause pain or discomfort.”
C. “You will be given some medication to cause amnesia of the test.”
D. “You will not be able to drink fluids for 24 hours before the study.”
A. “You will be lying on your abdomen for the examination procedure.”
B. “Portions of the procedure will cause pain or discomfort.”
C. “You will be given some medication to cause amnesia of the test.”
D. “You will not be able to drink fluids for 24 hours before the study.”
1171.
The nurse is caring for a client scheduled for a surgical repair of an
abdominal aortic aneurysm. Which assessment is most crucial during the
preoperative period?
A. Assessment of the client’s level of anxiety
B. Evaluation of the client’s exercise tolerance
C. Identification of peripheral pulses
D. Assessment of bowel sounds and activity
A. Assessment of the client’s level of anxiety
B. Evaluation of the client’s exercise tolerance
C. Identification of peripheral pulses
D. Assessment of bowel sounds and activity
1172. The nurse should carefully monitor the client for which common dysrhythmia that can occur during suctioning?
A. Bradycardia
B. Tachycardia
C. Ventricular ectopic beats
D. Sick sinus syndrome
A. Bradycardia
B. Tachycardia
C. Ventricular ectopic beats
D. Sick sinus syndrome
1173.
The nurse is performing discharge instructions for a client with an
implantable permanent pacemaker. What discharge instruction is an
essential part of the plan?
A. “You cannot eat food prepared in a microwave.”
B. “You should avoid moving the shoulder on the side of the pacemaker site for six weeks.”
C. “You will have to learn to take your own pulse.”
D. “You will not be able to fly on a commercial airliner with the pacemaker in place.”
A. “You cannot eat food prepared in a microwave.”
B. “You should avoid moving the shoulder on the side of the pacemaker site for six weeks.”
C. “You will have to learn to take your own pulse.”
D. “You will not be able to fly on a commercial airliner with the pacemaker in place.”
1174.
The nurse is completing admission on a client with possible esophageal
cancer. Which finding would not be common for this diagnosis?
A. Foul breath
B. Dysphagia
C. Diarrhea
D. Chronic hiccups
A. Foul breath
B. Dysphagia
C. Diarrhea
D. Chronic hiccups
1175.
A client arrives from surgery following an abdominal perineal resection
with a permanent ileostomy. What should be the priority nursing care
during the post-op period?
A. Teaching how to irrigate the ileostomy
B. Stopping electrolyte loss through the stoma
C. Encouraging a high-fiber diet
D. Facilitating perineal wound drainage
A. Teaching how to irrigate the ileostomy
B. Stopping electrolyte loss through the stoma
C. Encouraging a high-fiber diet
D. Facilitating perineal wound drainage
1176.
The nurse is making initial rounds on a client with a C5 fracture. The
client is in a halo vest and is receiving O2 at 40% via mask to a
tracheostomy. Assessment reveals a respiratory rate of 40 and O2
saturation of 88. The client is restless. Which initial nursing action
is most indicated?
A. Notifying the physician
B. Performing tracheal suctioning
C. Repositioning the client to the left side
D. Rechecking the client’s O2 saturation
A. Notifying the physician
B. Performing tracheal suctioning
C. Repositioning the client to the left side
D. Rechecking the client’s O2 saturation
1177.
A client has just finished her lunch, consisting of shrimp with rice,
fruit salad, and a roll. The client calls for the nurse, stating, “My
throat feels thick and I’m having trouble breathing.” What action should
the nurse implement first?
A. Place the bed in Trendelenburg position and call the physician.
B. Take the client’s vital signs and administer Benadryl 50mg PO.
C. Place the bed in high Fowler’s position and call the physician.
D. Start an Aminophylline drip and call the physician.
A. Place the bed in Trendelenburg position and call the physician.
B. Take the client’s vital signs and administer Benadryl 50mg PO.
C. Place the bed in high Fowler’s position and call the physician.
D. Start an Aminophylline drip and call the physician.
1178.
The nurse is caring for a client with cirrhosis of the liver. Which is
the best method to use for determining that the client has ascites?
A. Inspection of the abdomen for enlargement
B. Bimanual palpation for hepatomegaly
C. Daily measurement of abdominal girth
D. Assessment for a fluid wave
A. Inspection of the abdomen for enlargement
B. Bimanual palpation for hepatomegaly
C. Daily measurement of abdominal girth
D. Assessment for a fluid wave
1179.
A client arrives in the emergency room after a motor vehicle accident.
Witnesses tell the nurse that they observed the client’s head hit the
side of the car door. Nursing assessment findings include BP 70/34,
heart rate 130, and respirations 22. Based on the information provided,
which is the priority nursing care focus?
A. Brain tissue perfusion
B. Regaining fluid volume
C. Clearance of the client’s airway
D. Measures to increase sensation
A. Brain tissue perfusion
B. Regaining fluid volume
C. Clearance of the client’s airway
D. Measures to increase sensation
1180.
The home health nurse is visiting a 30-year-old with sickle cell
disease. Assessment findings include spleenomegaly. What information
obtained on the visit would cause the most concern? The client:
A. Eats fast food daily for lunch
B. Drinks a beer occasionally
C. Sometimes feels fatigued
D. Works as a furniture mover
A. Eats fast food daily for lunch
B. Drinks a beer occasionally
C. Sometimes feels fatigued
D. Works as a furniture mover
1181.
The nurse on the oncology unit is caring for a client with a WBC of
1500/mm3. During evening visitation, a visitor brings in a fruit basket.
What action should the nurse take?
A. Encourage the client to eat small snacks of the fruit.
B. Remove fruits that are not high in vitamin C.
C. Instruct the client to avoid the high-fiber fruits.
D. Remove the fruits from the client’s room.
A. Encourage the client to eat small snacks of the fruit.
B. Remove fruits that are not high in vitamin C.
C. Instruct the client to avoid the high-fiber fruits.
D. Remove the fruits from the client’s room.
1182.
The nurse is giving an end-of-shift report when a client with a chest
tube is noted in the hallway with the tube disconnected. What is the
most appropriate action?
A. Clamp the chest tube immediately.
B. Put the end of the chest tube into a cup of sterile normal saline.
C. Assist the client back to the room and place him on his left side.
D. Reconnect the chest tube to the chest tube system.
A. Clamp the chest tube immediately.
B. Put the end of the chest tube into a cup of sterile normal saline.
C. Assist the client back to the room and place him on his left side.
D. Reconnect the chest tube to the chest tube system.
1183.
A client with deep vein thrombosis is receiving a continuous heparin
infusion and Coumadin PO. INR lab test result is 8.0. Which intervention
would be most important to include in the nursing care plan?
A. Assess for signs of abnormal bleeding.
B. Anticipate an increase in the heparin drip rate.
C. Instruct the client regarding the drug therapy.
D. Increase the frequency of vascular assessments.
A. Assess for signs of abnormal bleeding.
B. Anticipate an increase in the heparin drip rate.
C. Instruct the client regarding the drug therapy.
D. Increase the frequency of vascular assessments.
1184.
Which breakfast selection by a client with osteoporosis indicates that
the client understands the dietary management of the disease?
A. Scrambled eggs, toast, and coffee
B. Bran muffin with margarine
C. Granola bar and half of a grapefruit
D. Bagel with jam and skim milk
A. Scrambled eggs, toast, and coffee
B. Bran muffin with margarine
C. Granola bar and half of a grapefruit
D. Bagel with jam and skim milk
1185.
A client with hepatitis C who has cirrhosis changes has just returned
from a liver biopsy. The nurse will place the client in which position?
A. Trendelenburg
B. Supine
C. Right side-lying
D. Left Sim’s
A. Trendelenburg
B. Supine
C. Right side-lying
D. Left Sim’s
1186.
The nurse is caring for a client who was admitted to the burn unit four
hours after the injury with second-degree burns to the trunk and head.
Which finding would the nurse least expect to find during this time
period?
A. Hypovolemia
B. Laryngeal edema
C. Hypernatremia
D. Hyperkalemia
A. Hypovolemia
B. Laryngeal edema
C. Hypernatremia
D. Hyperkalemia
1187.
The nurse is evaluating nutritional outcomes for a client with anorexia
nervosa. Which one of the following is the most objective favorable
outcome for the client?
A. The client eats all the food on her tray.
B. The client requests that family bring special foods.
C. The client’s weight has increased.
D. The client weighs herself each morning.
A. The client eats all the food on her tray.
B. The client requests that family bring special foods.
C. The client’s weight has increased.
D. The client weighs herself each morning.
1188.
The client who is two weeks post-burn with a 40% deep partial-thickness
injury still has open wounds. The nurse’s assessment reveals the
following findings: temperature 96.5°F, BP 87/40, and severe diarrhea
stools. What problem does the nurse most likely suspect?
A. Findings are normal, not suspicious of a problem
B. Systemic gram—positive infection
C. Systemic gram—negative infection
D. Systemic fungal infection
A. Findings are normal, not suspicious of a problem
B. Systemic gram—positive infection
C. Systemic gram—negative infection
D. Systemic fungal infection
1189.
The nurse assesses a new order for a blood transfusion. The order is to
transfuse one unit of packed red blood cells (contains 250mL) in a
two-hour period. What will be the hourly rate of infusion?
A. 50mL/hr
B. 62mL/hr
C. 125mL/hr
D. 137mL/hr
A. 50mL/hr
B. 62mL/hr
C. 125mL/hr
D. 137mL/hr
1190.
A client has signs of increased intracranial pressure. Which one of the
following is an early indicator of deterioration in the client’s
condition?
A. Widening pulse pressure
B. Decrease in the pulse rate
C. Dilated, fixed pupils
D. Decrease in level of consciousness
A. Widening pulse pressure
B. Decrease in the pulse rate
C. Dilated, fixed pupils
D. Decrease in level of consciousness
1191.
Which of the following statements by a client with a seizure disorder
who is taking topiramate (Topamax) indicates that the client has
understood the nurse’s instruction?
A. “I will take the medicine before going to bed.”
B. “I will drink 8 to 10 ten-ounce glasses of water a day.”
C. “I will eat plenty of fresh fruits.”
D. “I must take the medicine with a meal or snack.”
A. “I will take the medicine before going to bed.”
B. “I will drink 8 to 10 ten-ounce glasses of water a day.”
C. “I will eat plenty of fresh fruits.”
D. “I must take the medicine with a meal or snack.”
1192.
A client with terminal lung cancer is admitted to the unit. A family
member asks the nurse, “How much longer will it be?” Which response by
the nurse is most appropriate?
A. “This must be a terrible situation for you.”
B. “I don’t know. I’ll call the doctor.”
C. “I cannot say exactly. What are your concerns at this time?”
D. “Don’t worry, from the way things look, it will be very soon.”
A. “This must be a terrible situation for you.”
B. “I don’t know. I’ll call the doctor.”
C. “I cannot say exactly. What are your concerns at this time?”
D. “Don’t worry, from the way things look, it will be very soon.”
1193.
A client with a history of colon cancer is admitted to the oncology
unit. Laboratory results reveal a WBC of 1600/mm3 . What plans will the
nurse add to the care plan because of the WBC reading?
Select all that apply.
I. No sick visitors
II. Private room necessary
III. No aspirin products
IV. Low bacteria diet
V. Electric razors only
A. All of the Above
B. None of the Above
C. I and V only
D. I, II, IV
Select all that apply.
I. No sick visitors
II. Private room necessary
III. No aspirin products
IV. Low bacteria diet
V. Electric razors only
A. All of the Above
B. None of the Above
C. I and V only
D. I, II, IV
1194.
The nurse is caring for a client with a closed head injury. Fluid is
assessed leaking from the ear. What is the nurse’s first action?
A. Irrigate the ear canal gently.
B. Notify the physician.
C. Test the drainage for glucose.
D. Apply an occlusive dressing.
A. Irrigate the ear canal gently.
B. Notify the physician.
C. Test the drainage for glucose.
D. Apply an occlusive dressing.
1195.
The nurse has inserted an NG tube for enteral feedings. Which
assessment result is the best indicator of the tube’s stomach placement?
A. Aspiration of tan-colored mucus
B. Green aspirate with a pH of 3
C. A swish auscultated with the injection of air
D. Bubbling noted when the end of the tube is placed in liquid
A. Aspiration of tan-colored mucus
B. Green aspirate with a pH of 3
C. A swish auscultated with the injection of air
D. Bubbling noted when the end of the tube is placed in liquid
1196.
The nurse would identify which one of the following assessment findings
as a normal response in a craniotomy client post-operatively?
A. A decrease in responsiveness the third post-op day
B. Sluggish pupil reaction the first 24–48 hours
C. Dressing changes three to four times a day for the first three days
D. Temperature range of 98.8°F to 99.6°F the first 2–3 days
A. A decrease in responsiveness the third post-op day
B. Sluggish pupil reaction the first 24–48 hours
C. Dressing changes three to four times a day for the first three days
D. Temperature range of 98.8°F to 99.6°F the first 2–3 days
1197.
A client with alcoholism has been instructed to increase his intake of
thiamine. The nurse knows the client understands the instructions when
he selects which food?
A. Roast beef
B. Broiled fish
C. Baked chicken
D. Sliced pork
A. Roast beef
B. Broiled fish
C. Baked chicken
D. Sliced pork
1198. The nurse would expect to find which drug prescribed for a patient diagnosed with ALS?
A. Amantadine hydrochloride (Symmetrel)
B. Riluzole (Rilutek)
C. Lisinopril (Zestril)
D. Estrodial (Estrogel)
A. Amantadine hydrochloride (Symmetrel)
B. Riluzole (Rilutek)
C. Lisinopril (Zestril)
D. Estrodial (Estrogel)
1199. A client has a CVP monitor in place via a central line. Which would be included in the nursing care plan for this client?
A. Notify the physician of readings less than 3cm or more than 8cm of water.
B. Use the clean technique to change the dressing at the insertion site.
C. Elevate the head of the bed to 90° to obtain CVP readings.
D. The 0 mark on the manometer should align with the client’s right clavicle for the readings.
A. Notify the physician of readings less than 3cm or more than 8cm of water.
B. Use the clean technique to change the dressing at the insertion site.
C. Elevate the head of the bed to 90° to obtain CVP readings.
D. The 0 mark on the manometer should align with the client’s right clavicle for the readings.
1200.
A client is admitted to the chemical dependency unit for poly-drug
abuse. The client states, “I don’t know why you are all so worried; I am
in control. I don’t have a problem.” Which defense mechanism is being
utilized?
A. Rationalization
B. Projection
C. Dissociation
D. Denial
A. Rationalization
B. Projection
C. Dissociation
D. Denial
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