221) Which of the following are a result of antidiuretic hormone (ADH) secretion?
A. Sodium and water reabsorption
B. Urine concentration
C. Urine dilution
D. Potassium excretion and water reabsorption


ANSWER

220) A patient is preparing for an orthopedic surgery and the LPN is asked to help. For which of the following tasks must the RN confirm that the LPN has received special training?
A. Administering I.V. therapy
B. Ambulating the patient
C. Assisting the patient with a bath
D. Collecting a urine specimen

ANSWER

219) The nurse is caring for a patient with a hydromorphone (Dilaudid) PCA set at a basal rate of 0.1 mg per hour, with a 0.1 mg bolus every 10 minutes. The nurse finds the patient stuporous and difficult to arouse. After treating and stabilizing the patient, the nurse should:
A. Notify the physician and request a lower basal rate
B. Check the PCA pump to verify that the settings are correct
C. Request that the PCA be discontinued
D. Ask the patient to rate his pain

ANSWER

218) The nurse would teach a client that alcohol taken in conjunction with which of the following ordered medications can cause a reaction causing flushing, dizziness, pounding headache, sweating, abdominal cramps, nausea, irritability, and low blood pressure?
A) Cefoxitan (Mefoxin)
B) Metronidazole (Flagyl)
C) Clindamycin (Cleocin)
D) Ampicillin (Omnipen)

ANSWER

217) The nurse plans to administer which of the following intravenous (IV) treatments to a client for treatment of hyperkalemia associated with severe acidosis?
A) Calcium gluconate, to make the potassium shift from the intracellular fluid (ICF) to the extracellular fluid (ECF)
B) Insulin and dextrose, to make the client hypoglycemic
C) Sodium bicarbonate, to make the client alkalotic so the potassium will shift into the ECF
D) Normal saline (NS), to provide extra sodium so the potassium will move out of the ICF into the ECF

ANSWER

216) The client has the diagnosis of acquired immunodeficiency syndrome (AIDS). The nurse observes that the client is demonstrating changes in behavior that include memory difficulties, declining attention to personal hygiene, and frequent manifestations of angry and hostile behaviors. The nurse assists the client’s family and friends to understand this as an indication of which of the following?
A) Rapidly approaching death
B) Reversible symptoms of delirium
C) Chronic impairment of brain functioning
D) Treatable side effects of anti-AIDS medications

ANSWER

215) A client is being evaluated for a possible myocardial infarction. The nurse performs a 12-lead ECG for an episode of new chest pain. The nurse will monitor for which sign of acute myocardial injury?
A) ST depressions
B) ST elevations
C) New Q wave
D) New U wave

ANSWER

214) An order for which beta agonist should be questioned because it is contraindicated for a client with a history of atrial fibrillation?
A) Terbutaline (Brethine)
B) Pirbuterol (Maxair)
C) Isoproterenol (Isuprel)
D) Metaproterenol (Alupent)


ANSWER

213) When admitting a client with a diagnosis of cirrhosis, the nurse assesses the medications ordered. She should question the administration of which of the following?
A) Lactulose (Chronulac)
B) Neomycin (Mycifradin)
C) Meperidine (Demerol)
D) Acetaminophen (Tylenol)

ANSWER

212) Which of the following points should be included in a teaching plan for a client receiving medications to treat multiple sclerosis?
A) The signs and symptoms of pulmonary edema
B) The restriction of fluids
C) The requirement to remain restricted from crowds
D) The requirement to exercise to enhance muscle strength

ANSWER

211) A client at 10 weeks' gestation who has recently emigrated from Japan comes to the prenatal clinic because she is having some dark brown vaginal spotting, and is experiencing severe nausea and vomiting. The nurse interprets that these symptoms are compatible with which of the following conditions?
A) Gestational trophoblastic disease
B) Hyperemesis gravidarum
C) Placenta previa
D) Pregnancy-induced psychosis

ANSWER

210) The nurse writes on the worksheet for the shift to assess a client taking cholestyramine (Questran) for signs of possible deficiency of which vitamins?
A) Niacin and thiamine
B) Folic acid and Vitamin C
C) Vitamins A and D
D) Thiamine and cyanocobalamin

ANSWER

209) A 9-year-old male client with severe esophagitis is 12 hours status/post-Nissen fundoplication for gastroesophageal reflux. To implement appropriate nursing care, the nurse should do which of the following?
A) Encourage him to take small amounts of clear liquids every 4 hours.
B) Administer NG or gastrostomy feedings every 4 hours.
C) Ask him to choose a face on the Wong FACES pain rating scale.
D) Insert a pH probe to monitor esophageal acidity.

ANSWER

208) The nurse is caring for a client with a history of renal disease. The nurse most closely monitors the client for signs of nephrotoxicity if the client is ordered to receive which of the following medications?
A) Aminoglycoside antibiotics
B) Aspirin-containing drugs
C) Loop diuretics
D) Potassium supplements

ANSWER

207) A 4-year-old child with osteogenesis imperfecta (OI) is admitted to the hospital unit for an unrelated condition. The nurse determines that which nursing diagnosis has the highest priority for this child?
A) Impaired skin integrity related to cast
B) Pain related to fractures
C) Risk for injury related to disease state
D) Disturbed body image related to short stature

ANSWER

206) A female client complains of a burning, cramping pain in the top part of the abdomen that becomes worse in the middle of the afternoon and sometimes awakens her at night. She reports that eating something usually helps the pain go away but that the pain is now becoming more intense. Which of the following is the best conclusion for the nurse to draw?
A) These symptoms are consistent with an ulcer.
B) The client is probably developing cholelithiasis.
C) The client probably has indigestion and needs to watch what she eats.
D) A snack before bed should be recommended.

ANSWER

205) A 10-year-old client presents with weakness in the legs and history of the flu. The medical diagnosis is Guillain-Barré syndrome. It would be imperative for the nurse to inform the physician after observing which of the following?
A) Weak muscle tone in feet
B) Weak muscle tone in legs
C) Increasing hoarseness
D) Tingling in the hands


ANSWER

204) A child has been admitted to the hospital with a diagnosis of "rule out nephrosis." The nurse would assess the child for:
A) Hematuria.
B) Edema.
C) Petechial rash.
D) Dehydration.

ANSWER

203) The nurse needs to teach a client about newly prescribed sertraline (Zoloft). Which information is essential to include in the teaching? Select all that apply.
A) Sertraline is most often taken as a morning dose.
B) Constipation is a common side effect of sertraline.
C) Fever and flulike symptoms are bothersome but not dangerous side effects of sertraline.
D) Clients taking sertraline will usually recognize improvement within one week.
E) It is possible that sexual side effects will occur.


ANSWER

202) A client is being evaluated for hypothyroidism, and has had blood drawn to determine TSH and T4 levels. Which of the following would support the diagnosis?
A) An elevated TSH and elevated T4 levels
B) An elevated TSH and decreased T4 levels
C) A decreased TSH and elevated T4 levels
D) A decreased TSH and decreased T4 levels

ANSWER

201) A 68-year-old is admitted to the surgical unit after undergoing a total hip replacement. Which of the following interventions is most important to prevent dislocation of the prosthesis?
A. Maintain hip flexion of 90 degrees
B. Prevent abduction of the affected hip
C. Prevent internal rotation of the affected hip
D. Keep the affected hip adducted

ANSWER

200) A home health nurse is making a visit to a client who is terminally ill and whose condition is deteriorating. A family member reports to the nurse that his terminally ill father experienced rapid-onset diarrhea after eating breakfast. The nurse explains this was most likely due to:
A) Malabsorption.
B) Anal incontinence.
C) Fecal impaction.
D) Food poisoning.

ANSWER

199) A charge nurse on a pediatric unit has just been informed of a potential admission from the emergency department. Which of the following nurses should be assigned to admit the patient?
A. A nurse caring for a child with no family or visitors
B. A nurse who recently discharged two patients
C. A nurse preparing for a complex dressing change after surgery
D. A nurse caring for a child with multiple gastrointestinal bleeds

ANSWER

198) The nurse would monitor the client receiving which type of antihypertensive drug because it slows the AV node, and thus decreases the heart rate?
A) Angiotensin-converting enzyme (ACE) inhibitor
B) Beta blocker
C) Alpha blocker
D) Calcium channel blocker

ANSWER

197) A 60-year-old patient was examined by the nurse and the signs and symptoms indicate there is increased intracranial pressure, papilledema, and headache. There was no history of trauma and the vital signs showed BP of 120/70 mmHg, HR = 90 bpm, T = 98.9˚ F, RR = 23 cpm. With the assessment findings, the nurse thinks the patient has:
A. Brain tumor
B. Meningitis
C. Skull fracture
D. Encephalitis

ANSWER

196) An elderly client admitted with a diagnosis of heart failure has been taking furosemide (Lasix) for treatment of heart failure. Serum potassium level is 3.2 mEq/L. Which of the following ABG results would the nurse expect this client to manifest?
A) pH 7.20; PaCO2 50; HCO3- 22; PaO2 93
B) pH 7.30; PaCO2 48; HCO3- 36; PaO2 90
C) pH 7.49; PaCO2 36; HCO3- 30; PaO2 90
D) pH 7.50; PaCO2 49; HCO3- 18; PaO2 90

ANSWER

195) An elderly man is admitted to the hospital for possible urethritis. The nurse assesses the patient closely for what common symptom?
A. Dysuria and mucopurulent penile discharge
B. Hematuria and suprapubic pain
C. Hematuria and proteinuria
D. Hematuria and dysuria

ANSWER

194)A patient presents to the ER after being found unconscious and not breathing. Before endotracheal intubation, you get an arterial blood gas with which of the following results:

A. pH 7.28 PCO2 60 HCO3 26
B. pH 7.38 PCO2 45 HCO3 26
C. pH 7.31 PCO2 41 HCO3 18
D. pH 7.49 PCO2 50 HCO3 18

ANSWER

193) While assessing a newborn, the nurse suspects the presence of phenylketonuria. Which of the follow tests would confirm the diagnosis?
A. Guthrie test
B. Tandem mass spectrometry
C. Liver enzyme analysis
D. Urinalysis

ANSWER

192)The nurse is caring for a patient that sustained multiple fractures from a motor vehicle accident. Which nursing intervention is most important when caring for a patient on bedrest?

A. Reposition every 2 hours
B. Elevate the head of bed to promote lung expansion
C. Help with activities of daily living to help conserve the patient’s energy
D. Limit fluid intake to reduce edema

ANSWER

191) A nurse administers bacitracin ophthalmic ointment to a teenager with conjunctivitis. Which of the following symptoms indicates that the patient is experiencing an adverse effect of this medication?

A. Amblyopia
B. Diplopia
C. Strabismus
D. Blurred vision

ANSWER

190) The nurse has completed some child and family education for a child diagnosed with thalassemia. The medical plan of treatment includes blood transfusions when the anemia reaches a severe point. Which statement by the parents indicates a need for further education?
A) "Because of the anemia, my child will need extra rest periods."
B) "My child inherited this disorder from both of us."
C) "We should be alert to periods when our child seems paler than usual."
D) "My child needs an iron supplement."

ANSWER

189) The client is in the clinic for a follow-up visit following new onset of stable angina. The nurse should teach the client precipitating causes of angina such as exercise and stress. Which of the following should also be taught as a way to handle these precipitating causes?
A) Avoid these activities.
B) Perform such activities anyway.
C) Lead a sedentary lifestyle.
D) Use a nitroglycerin (NTG) tablet before the activity.

ANSWER

188) The nurse suspects hepatotoxicity evolving in a dark-skinned client who is on an antibiotic. In what area of the body should the nurse assess for jaundice?
A) Palms
B) Sclera
C) Conjunctivae
D) Hard palate of the oral cavity

ANSWER

187) Which of the following statements made by a parent of a child with osteogenesis imperfecta (OI) needs clarification by the nurse?
A) "My child may be able to participate in sports."
B) "There are no medications available to help this disease process."
C) "Surgery may be needed to place rods in the bone for stability."
D) "My child will need to be home schooled to protect him from injury."

ANSWER

186) You have been invited to talk to the Woman's Guild in your community about the cautions of aromatherapy. Which of the following would be correctly presented to the audience?
A) Aromatic oils are produced by a standard-quality formula.
B) The oils can be stored in any type of container.
C) The skin should always be tested for allergies by applying a small amount of oil to the area before treatment.
D) Oils should not be used during pregnancy.

ANSWER

185) A client who works in a mine presents to the Emergency Department with neurological problems. The nurse suspects which mineral imbalance could be a likely cause for this presentation?
A) Fluoride ingestion
B) Inhalation of manganese dust
C) Excess copper inhalation
D) Sodium deficiency due to dehydration
ANSWER

184)Which of the follow is likely to indicate abuse in a 6-year-old child?  *Select All That Apply

A. Exaggerated emotional response by the parents
B. Absent emotional response by the parents
C. Inappropriate physical appearance of the parents
D. Conflicting stories from the parents
E. Parents using vulgar language

ANSWER

183) The nurse anticipates that which of the following clients is at risk for hypermagnesemia?
A) An anorexic 16-year-old female
B) A 57-year-old alcoholic male
C) A 47-year-old female with a history of partial gastrectomy
D) A 62-year-old male with chronic renal failure

ANSWER

182) A 4-year-old child is assessed by the nurse. The child has fair skin, musty odor from the urine, stunted growth, and mental retardation. Based on this findings, the nurse should suspect which of the following metabolic disorders?

A. Branched-chain ketoaciduria
B. Celiac disease
C. Tay-Sach’s disease
D. Phenylketonuria

ANSWER

181) The nurse is caring for a client with a history of renal disease. The nurse most closely monitors the client for signs of nephrotoxicity if the client is ordered to receive which of the following medications?
A) Aminoglycoside antibiotics
B) Aspirin-containing drugs
C) Loop diuretics
D) Potassium supplements

ANSWER

180) The nurse is assessing a patient that underwent a unilateral adrenalectomy. To assess for hyperkalemia, the nurse should be alert for:

*Select All That Apply

A. Tremors
B. Hypoventilation
C. Muscle weakness
D. Tachycardia
E. Arrhythmia
F. Bradycardia

ANSWER

179) A client has new onset type I diabetes mellitus (DM). He asks you why he needs to check his blood glucose level so frequently. You explain that frequent coverage with insulin to keep his blood glucose level between 80 and 155 mg/dL is important for which of the following reasons?
A) Chronic elevated blood glucose levels damage cells and causes multiple organ damage.
B) High glucose levels cause the body to use proteins for energy, causing lactic acidosis.
C) Early identification of hypoglycemia before the onset of symptoms is easier to treat.
D) Carbohydrates are constantly being converted to glucose and transported in the blood by insulin.


ANSWER

178) Of the following clients, the one who is at high risk for a functional paralytic intestinal obstruction is the one:
A) With a tumor of the colon.
B) Who develops adhesions after a bowel resection.
C) Who develops a paralytic ileus after abdominal surgery.
D) With a twisted colon.

ANSWER

177) The nurse is assessing the client's surgical wound in the postoperative period. Which finding indicates the first stage of healing?
A) Inflammation in the wound edges
B) Bleeding around the incision
C) Clot binding the wound edges
D) Collagen synthesis

ANSWER

176) Which of the following findings would the nurse observe in a client who is successfully using music therapy?
A) Increased peripheral temperature
B) Increased respiratory rate
C) Increased heart rate
D) Increased blood pressure

ANSWER

175) A client has been receiving high doses of glucocorticoids for several weeks. The client asks the nurse when he can stop taking the medication. The nurse's response incorporates which of the following information?
A) Even at high doses, adverse reactions are unlikely if the medication is abruptly withdrawn.
B) If steroid medication is withdrawn suddenly, a client could die of acute adrenal insufficiency.
C) The client could experience severe psychological symptoms when the medication is withdrawn.
D) Tapering of the medication requires daily assessment of serum chemistries.

ANSWER

174) The following medication orders were discovered in a client’s chart. The nurse should note and implement all of the orders except which of the following?
A) Digoxin (Lanoxin) 0.25 mg PO daily
B) Zolpidem (Ambien) 10 mg PO at bedtime PRN
C) Furosemide (Lasix) oral solution 40 mg PO daily
D) Acetaminophen (Tylenol) 2 tablets PO q4 hours PRN for headache

ANSWER

173) A patient is prescribed tamoxifen, 20 mg P.O. twice a day for newly diagnosed metastatic breast cancer. While providing education to the patient, the nurse should include which possible side effect?

A. Arrhythmias
B. Hot flashes
C. Ototoxicity
D. Hyperglycemia

ANSWER

172) A 2-month-old infant has been admitted with a diagnosis of sepsis. The nurse would monitor the child for evidence of:
A) Hypothermia.
B) Rash.
C) Sunken fontanels.
D) Glucosuria.


ANSWER

171) The client taking diltiazem hydrochloride (Cardizem) 30 mg PO qid is experiencing symptoms of toxicity. Which of the following assessments should be the nurse's highest priority?
A) Client's body temperature, looking for elevation
B) Rate, depth and regularity of the client's respirations
C) Client's daily weight, looking for weight loss
D) If client has ingested grapefruit juice with meals


ANSWER

170) A patient with valvular disease comes to the emergency department with complaints of syncope and dyspnea on exertion. The nurse suspects:

A. Aortic regurgitation
B. Mitral prolapse
C. Aortic stenosis
D. Mitral stenosis

ANSWER

169) A 30-year-old patient has been treated at the emergency department for a head injury and is to be discharged. As the nurse provided health instruction to the family, she explained the signs of complications that can possibly occur within the first 24 hours and the appropriate measures to perform in case they occur. Which statement by the patient’s spouse requires further teaching by the nurse?

A. I need to check on my husband while he is sleeping
B. My husband will be fine if he takes a long nap
C. If my husband starts to vomit, it means I have to call the doctor
D. I’ll bring my husband to the hospital if he has trouble talking

ANSWER

168) An infant is admitted with an acyanotic heart defect. Which assessment finding should be discussed with the physician?
A) Heart murmur
B) Dyspnea
C) Weight gain
D) Eupnea

ANSWER

167) The nurse places highest priority on implementing which of the following measures on the surgical unit on the first postoperative day following surgical repair of an aneurysm?
A) Administer anticoagulant therapy.
B) Position the legs in Trendelenburg position.
C) Apply elastic stockings to both legs.
D) Palpate peripheral pulses q2-4h.


ANSWER

166) The nurse is irrigating the ears of an older adult man with a cerumen impaction. The nurse would stop the procedure if
A) the man became nauseated.
B) the irrigating fluid did not return.
C) cerumen and fluid are expelled.
D) the man says he can’t hear as well.

ANSWER

165) A client is taking sertraline (Zoloft). The nurse explains to the client that how much time will pass before the onset of the medication occurs?
A) 5-7 days
B) 1-4 weeks
C) 4-6 weeks
D) 4-8 weeks

ANSWER

164) A client is admitted with 25 percent total body surface area (TBSA) burned. The rationale for administering intravenous fluids initially is which of the following?
A) The intravascular compartment becomes dehydrated.
B) The interstitial compartment becomes overhydrated.
C) The intravascular compartment becomes overhydrated.
D) The interstitial compartment becomes dehydrated.

ANSWER

163) A client experiencing urinary calculi asks the nurse what makes a stone in the body. The nurse's best answer is that the majority of kidney stones consist of:
A) Uric acid.
B) Cystine.
C) Sturvite.
D) Calcium.

ANSWER

162) In planning postpartum nursing care for a patient with cardiac disease, the nurse would question which of the following physician orders:

A. High fiber diet
B. Monitor vital signs every 2 hours
C. Strict monitoring of input and output
D. High fluid intake

ANSWER

161) Which statement by an 8-year-old girl who has asthma indicates that she understands the use of a peak expiratory flow meter?
A) "My peak flow meter can tell me if an asthma episode might be coming, even though I might still be feeling okay."
B) "When I do my peak flow, it works best if I do three breaths without pausing in between breaths."
C) "I always start with the meter reading about halfway up. That way, I don t waste any breath."
D) "If I use my peak flow meter every day, I will not have an asthma attack."

ANSWER

160) A client is taking metyrapone (Metopirone), and experiences an adrenal crisis. Which of the following most likely predisposed the client to this occurrence?
A) Cortisol synthesis has increased.
B) The client has adrenal insufficiency.
C) The client has type 1 diabetes mellitus.
D) The client has no adrenal insufficiency.

ANSWER

159) A 59-year-old patient was advised to have a prostate-specific antigen blood test. After the PSA screening test was done, the patient asked the nurse what factors increase the risk of prostate cancer. The nurse correctly responds by saying all of the following, except:

A. Age
B. Hormones
C. Familial adenomatous polyposis
D. Folic acid supplementation

ANSWER

158) An ambulatory care nurse is working with a client who has come to the clinic because of diarrhea. The nurse determines that the client needs instruction about management of this health problem when the client states to do which of the following?
A) Avoid dairy products.
B) Take Kaopectate as directed.
C) Contact health care provider if symptoms not resolved in two days.
D) Use a bulk-forming agent, such as Metamucil.

ANSWER

157) A client experiences an anaphylactic reaction after taking an antibiotic for the first time. The results of this Type I hypersensitivity response are caused by:
A) A histamine precursor causing anaphylaxis.
B) Antigen-IgE-mast cell interaction.
C) Cell-mediated response.
D) Massive numbers of destroyed red blood cells.

ANSWER

156) A 27-year-old primigravida asks the nurse how much iron she needs during her pregnancy. The correct response of the nurse is:

A. 150 mg per day
B. 30 mg per day
C. 18 mg per day
D. 1 gram per day

ANSWER

155) The client with phimosis will experience difficulty with:
A) Replacing the retracted foreskin.
B) Complete bladder emptying.
C) Retracting the foreskin.
D) Maintaining an erection.

ANSWER

154) Which of the following would be expected in the uremic stage of end-stage renal disease and to contribute to death of the client?
A) Respiratory infection
B) GI disturbance
C) Neurologic complication
D) Cardiovascular disease

ANSWER

153) In educating a group of clients with pulmonary disorders about the use of pursed-lip breathing, the nurse is asked how this technique helps them to breathe. The best response would be that pursed-lip breathing:
A) Improves lung expansion.
B) Reduces anxiety that increases oxygen demand.
C) Keeps airways open.
D) Helps the client regain control of the attack.

ANSWER

152) The rehabilitation nurse is admitting a client following spinal cord injury. The nurse concludes that the client has developed Brown-Séquard syndrome after assessing which of the following in the client?
A) Ipsilateral motor loss above the lesion
B) Contralateral loss of proprioception
C) Hyperanesthesia below the level of the lesion
D) Ipsilateral motor loss below lesion


ANSWER

151) Which of the following viral infections has been associated with Guillian-Barré syndrome?
A) Human immunodeficiency virus (HIV)
B) Epstein-Barr
C) Cytomegalovirus (CMV)
D) Influenza

ANSWER

150) An immunocompromised patient has been prescribed amantadine (Symmetrel) for the treatment of influenza type A. The nurse instructs the patient about which common side effect related to amantadine’s action on dopamine receptors?

A. Urinary retention
B. Extrapyramidal symptoms
C. Nausea
D. Blurred vision

ANSWER

149) The nurse concludes that a client is at risk for pregnancy-induced hypertension (PIH) when the vital signs taken today show that the blood pressure has increased during pregnancy from:
A) 90/56 to 110/70.
B) 100/60 to 130/76.
C) 122/80 to 138/86.
D) 134/80 to 140/88.

ANSWER

148) Which of the following nursing diagnoses is the top priority during a client's first outbreak of genital herpes?
A) Pain
B) Sexual dysfunction
C) Anxiety
D) Risk for infection

ANSWER

147) The nurse is assessing a 7-year-old patient and auscultates expiratory wheezes throughout the lungs. The nurse should administer which prescribed medication?

A. Salmeterol (Serevent)
B. Theophylline (Theolair)
C. Albuterol (Ventolin)
D. Fluticasone/salmeterol (Advair)

ANSWER

146) The nurse assesses the client with rheumatoid arthritis for which of the following characteristic joint changes?
A) Swan-neck deformity and ulnar deviation
B) Heberden’s and Bouchard’s nodes
C) Tophi
D) Charcot’s joints

ANSWER

145) A client with chronic renal failure has a magnesium level of 2.8 mEq/L. When reviewing the client’s dietary history, the nurse identifies which of the following frequently eaten foods as a possible cause of this laboratory value? Select all that apply.
A) Hot chocolate
B) Apples
C) Pork sausage
D) Spinach salad
E) Swiss cheese

ANSWER

144) A 1-year-old child has been diagnosed with cerebral palsy. The child has the spastic form that affects all extremities. Which of the following nursing diagnoses would be appropriate for a child at this age?
A) Urinary incontinence
B) Feeding self-care deficit
C) Impaired thought processes
D) Impaired verbal communication


ANSWER

143) A nurse is caring for a patient receiving ethosuximide (Zarontin) for the treatment of epilepsy. Which symptom would indicate to the nurse that the patient is experiencing a side effect of this medication?

A. Nausea
B. Anxiety
C. Urinary retention
D. Blurred vision

ANSWER

142) The nurse is giving general information about antihypertensive medications to a young female client with a history of hypertension. The nurse includes that pregnant or lactating women should avoid using which of the following types of antihypertensives?
A) Vasodilators
B) Diuretics
C) Angiotensin-converting enzyme (ACE) inhibitors
D) Calcium channel blockers

ANSWER

141) Upon return of the closed-head injury client from CT scan, the head of the bed is maintained at 30 degrees and the client is positioned on his side with a towel roll placed vertically under the pillow. This unique positioning facilitates:
A) Prevention of pulmonary embolism.
B) Venous drainage from the brain.
C) Airway management.
D) Intracranial pressure (ICP) readings.

ANSWER

140) The nurse practitioner documents in a client record that a client has closed comedones. The nurse explains to the client that this means the lesions are what type of skin eruption?
A) Whiteheads
B) Blackheads
C) Pustules
D) Cysts

ANSWER

139) Theophylline (Theo-dur) is ordered for a client with emphysema for the main purpose of relaxing bronchial smooth muscle. Which of the following indicate(s) therapeutic effects of the drug?
A) Decreased heart rate
B) Thinner, clear-to-white secretions
C) Eupnea respirations
D) Increasing respiratory rate


ANSWER

138) In planning nutritional intake for a pregnant woman who is anemic, which of the following foods would be the best food choice to increase the intake of iron?
A) Hamburger with enriched bun
B) Tossed salad with fat-free dressing
C) Fresh fruit
D) Cheese and milk


ANSWER

137) A client with anemia has a nursing diagnosis of activity intolerance. Which of the following nursing interventions should the nurse implement?
A) Space interventions and encourage rest periods.
B) Teach client the basics of good nutrition.
C) Promote active or passive range of motion activities
D) Teach client to change position slowly to prevent dizziness

ANSWER

136) The nurse is caring for an 8-year-old with increased intracranial pressure. Which of the following statements by the parents would indicate the need to reexplain the purpose for elevating the head of the bed 15 to 30 degrees?

A. Reduces the risk of DVTs
B. Maintains an adequate cerebral perfusion pressure
C. Help increase venous outflow
D. Helps reduce ICP

ANSWER

135) The nurse teaches a client with lactose intolerance to check food labels for which additives, since they may cause gas and bloating? Select all that apply.
A) Casein
B) Sodium phosphate
C) Lecithin
D) Whey
E) Maltodextrin

ANSWER

134) The nurse is caring for a patient who recently underwent an abdominal aortic aneurysm repair. The nurse monitors the patient for which complication?

A. Hemorrhage
B. Pulmonary embolism
C. Infection
D. Acute renal failure

ANSWER

133) A patient who uses a fentanyl (Duragesic) patch for chronic cancer pain complains to the nurse of the rapid onset of pain at a level 9 (of a 0-10 scale) and requests “something for pain that will work quickly.” The best way for the nurse to document this information is as
a. breakthrough pain.
b. neuropathic pain.
c. somatic pain.
d. referred pain.

ANSWER

132) Which assessment information is most important for the nurse to obtain to evaluate whether treatment of a patient with anaphylactic shock has been effective?
a. Heart rate
b. Orientation
c. Blood pressure
d. Oxygen saturation

ANSWER

131) A nurse is assessing a patient who is receiving a nitroprusside (Nipride) infusion to treat cardiogenic shock. Which finding indicates that the medication is effective?
a. No new heart murmurs
b. Decreased troponin level
c. Warm, pink, and dry skin
d. Blood pressure 92/40 mm Hg

ANSWER

130) A nurse is caring for an obese patient with right lower lobe pneumonia. Which position will be best to improve gas exchange?
a. On the left side
b. On the right side
c. In the tripod position
d. In the high-Fowler’s position

ANSWER

129) A 22-year-old patient who experienced a near drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period?
a. Auscultate heart sounds.
b. Palpate peripheral pulses.
c. Auscultate breath sounds.
d. Check pupil reaction to light.


ANSWER

128) A 19-year-old is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the left hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. The nurse will anticipate giving
a. tetanus immunoglobulin (TIG) only.
b. TIG and tetanus-diphtheria toxoid (Td).
c. tetanus-diphtheria toxoid and pertussis vaccine (Tdap) only.
d. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap).


ANSWER

127) A patient is being evaluated for polycystic kidney disease (PKD). The nurse assesses the patient expecting to note which common symptoms? Select All That Apply

A. Lower back or flank pain that worsens with activity
B. Hematuria
C. Nausea
D. Adrenal crisis
E. Fever

ANSWER

126) The nurse is assessing a child with pulmonary valve stenosis. The nurse would expect to find which of the following?
A. Clubbing and exertional dyspnea
B. A systolic murmur heard over the left sternal border
C. A thrill may be heard
D. Severe cyanosis at birth

ANSWER

125) A client with an infection caused by amebiasis will most likely have gastrointestinal symptoms. Another site that could be affected is the:
A) Lungs
B)Brain
C)Liver
D)Kidney


ANSWER

124) The client is experiencing severe itching with a skin disorder. Which of the following drugs, if ordered, would the nurse administer as an appropriate oral preparation to decrease the itching?
A) Cimetidine (Tagamet)
B) Lorazepam (Ativan)
C) Hydroxyzine (Atarax)
D) Bupivacaine (Sensorcaine)

ANSWER

123) The nurse working in a pediatric clinic concludes that which assessment finding in a child indicates a risk for visual impairment?
A) Delayed language development
B) Excessive rubbing of the eyes
C) Disinterest in watching television
D) Bilateral symmetric corneal light reflex

ANSWER

122) When assessing the client with urinary calculi, an important subjective finding would be:
A) Allergies to sulfonamides.
B) Father of client who has had urinary stones twice.
C) Last urinary tract infection 2 months ago.
D) Alcohol intake of two six-packs of beer per day.


ANSWER

121) The nurse caring for a client with a calcium imbalance places highest priority on nursing interventions that help to manage:
A) Renal signs and symptoms.
B) Cardiac changes.
C) Hematologic disorders.
D) Neuromuscular clinical manifestations.

ANSWER

120) A client with angina has been instructed about the use of sublingual nitroglycerin. Which of the following statements made to the nurse indicates a need for FURTHER teaching?
 A)  "I will rest briefly right after taking one tablet."
 B)  "I can take 2-3 tablets at once if I have severe pain."
 C)  "I'll call the doctor if pain continues after 3 tablets 5 minutes apart."
 D)  "I understand that the medication should be kept in the dark bottle."

ANSWER

119) While assessing the vital signs in children, the nurse should know that the apical heart rate is preferred until the radial pulse can be accurately assessed at about
 A)  One year of age
 B)  Two years of age
 C)  Three years of age
 D)  Four years of age

ANSWER

118) The nurse is teaching parents of a 7 month-old about adding table foods. Which of the following is an APPROPRIATE finger food?
 A)  Hot dog pieces
 B)  Sliced bananas
 C)  Whole grapes
 D)  Popcorn

ANSWER

117) The nurse is caring for a client who has altered cerebral tissue perfusion related to a subarachnoid hemorrhage. To reduce the risk of rebleeding, the nurse should plan to
 A)  Restrict visitors to immediate family
 B)  Arouse the client frequently
 C)  Keep client's hips flexed at 120 degrees
 D)  Apply warming blankets

ANSWER

116) A client with peptic ulcer disease reports
that he has been nauseated most of the day and is
now feeling light-headed and dizzy. Based upon
these fi ndings, which nursing actions would be most
appropriate for the nurse to take? Select all that
apply.
1. Administering an antacid hourly until nausea
subsides.
2. Monitoring the client’s vital signs.
3. Notifying the physician of the client’s symptoms.
4. Initiating oxygen therapy.
5. Reassessing the client in an hour.


ANSWER

115) A 28-year-old primigravida goes to the clinic for her prenatal visit. Which of the following prenatal assessment procedures is not routinely included?

A. HIV testing
B. Nutritional needs
C. Pelvimetry
D. Personal and Family history
E. Complete blood count

ANSWER

114) The nurse teaches the client with cirrhosis
that he is achieving the expected effect of lactulose
(Cephulac) when he has:
1. One regular bowel movement a day.
2. Two to three soft stools per day.
3. Four to five loose stools per day.
4. Five to six loose stools per day.


ANSWER

113) Which of the following hospitalized clients is
at risk to develop parotitis?
1. A 50-year-old client with nausea and vomiting
who is on nothing-by-mouth status.
2. A 75-year-old client with diabetes who has
ill-fi tting dentures.
3. An 80-year-old client who has poor oral
hygiene and is dehydrated.
4. A 65-year-old client with lung cancer who
has a feeding tube in place.



ANSWER

112) A nursing assistant interrupts the performance of a ritual by a client with obsessivecompulsive
disorder. What is the most likely client reaction?
1. Anxiety
2. Hostility
3. Aggression
4. Withdrawal


ANSWER

111) A nurse is assessing a group of older adults. Which should the nurse consider to be
least likely to be affected by aging?
1. Sense of taste or smell
2. Gastrointestinal motility
3. Muscle or motor strength
4. Strategies to handle stress

ANSWER

110) A client with a chronic mental illness who
does not always take her medications is separated
from her husband and receives Supplemental Security
Income. She lives with her mother and older
sister and manages her own medication. The client’s
mother is in poor health and receives Social Security
benefi ts. The client’s sister works outside the home,
and the client’s father is dead. Which of the following
issues should the nurse need to address fi rst?
1. Family.
2. Marital.
3. Financial.
4. Medication.


ANSWER

109) The client has been prescribed lisinopril
(Prinivil) to treat hypertension. The nurse should
assess the client for which of the following electrolyte
imbalances?
 1. Hyponatremia.
 2. Hypocalcemia.
 3. Hyperkalemia.
 4. Hypermagnesemia.

ANSWER

108) Which of the following interventions is most
appropriate for a client who has stomatitis?
 1. Drinking hot tea at frequent intervals.
 2. Gargling with antiseptic mouthwash.
  3. Using an electric toothbrush.
 4. Eating a soft, bland diet.

ANSWER

107) A client who has glaucoma has been prescribed
timolol (Timoptic) eyedrops. Which of the
following instructions should the nurse give the
client about the administration of the eyedrops?
1. Instill the eyedrops whenever the eyes feel
irritated.
2. The medication may cause some transient eye
discomfort.
3. Keep the medication refrigerated between
doses.
4. The need to use the eyedrops will be reevaluated
after 1 month.

ANSWER

106) The nurse is making a home visit with a client
diagnosed with Alzheimer’s disease. The client
recently started on lorazepam (Ativan) due to
increased anxiety. The nurse is cautioning the family
about the use of lorazepam (Ativan). The nurse
should instruct the family to report which of the
following signifi cant side effects to the health care
provider?
1. Paradoxical excitement.
2. Headache.
3. Slowing of refl exes.
4. Fatigue.

ANSWER

105) A 10-year old child is admitted to the hospital

with complications related to chickenpox. The

nurse should do which of the following to prevent

the transmission of the infection to other children

on the unit? Select all that apply.

1. Place the child on contact isolation.

2. Wear a gown, mask, and gloves before entering

the room.

3. Place the child in a room with a 10-year-old

who has had chickenpox.

4. Place the child in a negative air-flow room.

5. Maintain isolation until lesions have

disappeared.)

ANSWER

104) What behavior does a nurse expect of a newborn about 1 hour after birth?
1. Crying and cranky
2. Hyperresponsive to stimuli
3. Relaxed and sleeping quietly
4. Intensely alert with eyes wide open

ANSWER

103) Cimetidine (Tagamet) may also be used to

treat hiatal hernia. The nurse should understand

that this drug is used to prevent which of the

following?

1. Esophageal refl ux.

2. Dysphagia.

3. Esophagitis.

4. Ulcer formation.

ANSWER

102)What concept of death should a nurse expect a preschool-age child to have?

1. Cessation of life

2. Reversible separation

3. Happening that affects old people

4. Someone who takes one away from the family

ANSWER

101) An older adult tells the nurse,"I regret many of the choices i have made during my life."Which of Erikson's developmental tasks does the nurse recognize that the client has probably failed to accomplish?
A. Ego interity despair
B. Identity versus role disffusion
C.Generativity versus stagnation
D.Autonomy versus shame and doubt

ANSWER

100)A nurse is assessing a 5-year-old with multiple deformities of the limbs and joints. She also has a thin upper lip, small teeth, and trouble learning in school. The nurse suspects that these signs are most likely the result of which of the following?

A. Down’s syndrome
B. Mercury poisoning
C. Fetal alcohol syndrome (FAS)
D. Klinefelter syndrome

ANSWER

99) Therapeutic nurse-client interaction occurs when the nurse
 A)  Assists the client to clarify the meaning of what the client is communicating
 B)  Interprets the client's covert communication
 C)  Praises the client for appropriate behavior
 D)  Advises the client on ways to resolve problems

ANSWER

98)A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic?
A) Bruising at the operative site
B) Elevated heart rate
C) Decreased platelet count
D) No bowel movement for 3 days

ANSWER

97) Clients receiving oprelvekin (Neumega) should be assessed frequently for signs and symptoms of which of the following?
A) Dehydration
B) Congestive heart failure (CHF)
C) Anxiety
D) Hyperuricemia


ANSWER

96) The nurse is caring for a patient suspected of having cancer of the large intestine. The nurse understands that adenocarcinomas of the large intestine are most common in the:
A. Ascending colon
B. Descending colon
C. Transverse colon
D. Rectosigmoid colon

ANSWER

95) The nurse is reviewing the x-ray of a patient with a fractured tibia. The x-ray shows a fracture diagonal to the bone’s long axis. What type of fracture is this?

A. Transverse fracture
B. Comminuted fracture
C. Linear fracture
D. Oblique fracture

ANSWER