36) A client with antisocial personality is trying to convince a nurse that he deserves special privileges and that an exception to the rules should be made for him. Which of the following responses is the most appropriate?
a. “I believe we need to sit down and talk about this.”
b. “Don’t you know better than to try to bend the rules?”
c. “What you’re asking me to do is unacceptable.”
d. “Why don’t you bring this request to the community meeting?”



ANSWER

35)The nurse teaches a client that the level of anxiety that best enhances an individual’s  power of perception is :

A) Mild

B ) Panic

C) Severe

D)Moderate

ANSWER 

34) A nurse is orienting a newly employed RN. Which of the following statements by the new nurse indicates a lack of understanding about oxygen saturation?

A) "Oxygen saturation is only assessed by analyzing the PaO₂."

B) "The SaO₂ indicates how well the blood is oxygenated."

C) "The SaO₂ reflects the amount of oxygen that is bound to a hemoglobin molecule."

D) "Oxygen saturation can be affected by acid-base balance."

ANSWER

33) The nurse evaluates the effectiveness of therapy with bilberry by monitoring for which of the following outcomes?

A) Decreased urinary frequency, nocturia and dysuria

B) Relief of diarrhea

C) Relief of night sweats and hot flashes

D) Reduction of symptoms of cold/influenza

ANSWER

32) A patient is admitted to the psychiatric unit for suicidal ideation. The physician prescribes escitalopram and asks the nurse to review the side effects with the patient. The nurse should include which common side effect in the patient’s education?

A. Confusion

B. Constipation

C. Sexual dysfunction

D. Weight Loss

ANSWER

31) A patient with full-thickness circumferential burns to the left arm is in need of an escharotomy. The nurse understands that the desired outcome of this procedure is:

A. Reduce arm edema
B. Debridement of infected tissue
C. Return of circulation distal to the burn
D. Reduce scarring

ANSWER

30) The nurse is caring for a patient with chronic renal failure (CRF) that has developed decreased erythropoietin synthesis. The nurse assesses the patient for:

A. Weakness and fatigue
B. Nausea and dizziness
C. Dyspnea and intercostal retractions
D. Cyanosis and hypercapnia

ANSWER

29) The nurse is assessing a 4-year-old complaining of a fever, chills, headache, and malaise with firm and tender cervical lymph nodes. What laboratory test is used to confirm the diagnosis of infectious mononucleosis?
A. WBC count revealing leukocytosis
B. CBC revealing increased lymphocytes
C. Positive heterophile antibody test
D. Positive Epstein-Barr virus antibody test

ANSWER

28) The nurse would question a client with balanitis about complaints of which of the following?
A) Vaginal discharge
B ) Pain with urination
C) Spontaneous urethral discharge
D) Back pain

ANSWER

27) A child is being treated for nephrotic syndrome. The nurse has told the mother that it is important to keep the child’s skin clean and dry. The mother asks why. The nurse’s response is based on the knowledge that
A) the skin is fragile secondary to electrolyte deficiency.
B) frequent urination may leave moisture on the skin that predisposes breakdown.
C) dietary restrictions make fighting infection hard.
D) the condition causes a reduction of gamma globulin in the body.

ANSWER

26) The nurse anticipates that which of the following clients admitted to the nursing unit is in the most severe catabolic pattern of metabolism?
A) A 12-year-old with acute appendicitis
B ) A 22-year-old pregnant client with slight painless vaginal bleeding
C) A client who is 5 days postoperative for femoropopliteal bypass
D) A client who was admitted 3 days ago with multiple trauma

ANSWER

25) The nurse is examining a client who is at 12 weeks gestation. The examiner would expect to find the fundus at which of the following locations?
A) 3 cm below the sternum
B) The level of the umbilicus
C) The level of the symphysis pubis
D) 3 cm below the umbilicus


ANSWER

24) If a newborn does not pass meconium during the first 36 hours of life, which of the following is the most appropriate action by the nurse?

A) Observe the anal area for fissures.

B) Notify the physician.

C) Increase the amount of oral feedings.

D) Measure the abdominal girth.

ANSWER

23) The nurse develops which goal as most realistic for a client who is being referred for dietary counseling and has been diagnosed with Pickwickian syndrome?
A) Maintain current body weight.
B) Increase caloric intake by 2,000 calories.
C) Follow prescribed weight loss plan.
D) Increase fluids to thin secretions and maintain respiratory effort.

ANSWER

22) In addition to prevention of pregnancy, oral contraceptives would provide benefits for a client with which of the following problems?
A) Pelvic inflammatory disease
B) Severe facial acne
C) Chloasma
D) Gallbladder disease

ANSWER

21) The nurse is teaching a client about long-term use of therapeutic (additional) corticosteroid medication. Which of the following is the best statement that indicates client understanding of the concepts taught?
A) "It is normal to have some hair loss."
B) "I should eat more to prevent excessive weight loss."
C) "I should eat 4 to 6 servings of food high in calcium."
D) "I should take aspirin for flu or cold symptoms."

ANSWER

20) When assessing the client with chronic pain, the nurse acquires essential data for planning care when asking the client to quantify:
A) The severity of the pain using a 1 to 10 scale.
B) How the pain affects the client's daily life.
C) What the client thinks is causing the pain.
D) What the client does to relieve the pain.

ANSWER

19) A client who needs to take a histamine H2 antagonist also has a history of several health problems. The nurse explains to this client that which histamine antagonist should be avoided because it has the greatest number of drug interactions?
A) Famotidine (Pepcid)
B) Ranitidine (Zantac)
C) Nizatidine (Axid)
D) Cimetidine (Tagamet)

ANSWER

18) A client with cancer has a calcium level of 11.8 mg/dL. Which of the following symptoms 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

ANSWER

17) A client is discharged 12 hours after a vaginal delivery. Which of the following findings should the nurse teach the client to notify the physician immediately if it occurs?

A) Tender lump in one breast that disappears after breastfeeding
B) Temperature of 100.0°F
C) Urgency with urination
D) Frequent tearful episodes

ANSWER

16) A client asks the nurse how she can live without her gallbladder. In order to respond to this client, the nurse must have which understanding of the hepatobiliary system?
A) The liver produces about 1,000 mL of bile per day.
B) The gallbladder makes about 90 mL of bile per day.
C) The liver concentrates bile more than 10 times.
D) The gallbladder dilutes and releases bile.

ANSWER

15) An individual who is HIV-positive and who develops memory loss, difficulty concentrating, euphoria, and lethargy is developing which of the following?
A) Alzheimer's disease
B) Senile dementia
C) AIDS dementia complex
D) Wasting syndrome

ANSWER

14) A client with cirrhosis of the liver and esophageal varices suddenly begins vomiting copious amount of dark-colored blood. The sign/symptom that is least expected would be which of the following:
A) Hypertension.
B) Pain.
C) Melena.
D) High ammonia level.

ANSWER

13)The client asks the nurse about the difference between dextromethorphan (Robitussin DM) and Dimetane-DC. The nurse's response should be:

A) "Dextromethorphan contains a narcotic."
B) "Dimetane-DC is non-narcotic."
C) "Dextromethorphan is an opioid antitussive that contains codeine."
D) "Dimetane-DC is an opioid antitussive that contains codeine."

ANSWER

12) A client who has been taking bethanechol chloride (Urecholine) for three days begins to complain of abdominal pain and difficulty breathing. After assigning another staff member to remain with the client, the nurse checks to see that which medication is available on the nursing unit?

A) Phytonadione (AquaMEPHYTON)

B) Atropine sulfate (generic)

C) Oxybutynin (Ditropan)

D) Epinephrine (Adrenalin)

ANSWER

11)A client states, "I am always late for everything because I can't leave my room without checking every drawer and door to make sure they are locked. If I don't do that, I get so worried that I have to go back. I can't seem to stop my behavior." The nurse should take which action at this time?

A)Allow the client adequate time to carry out the rituals.
B)Explore childhood experiences that may have led to the behavior.
C)Encourage the client to remain in the room until the urge to recheck has decreased.

D)Remind the client that the staff will not allow others to enter the room.

ANSWER

10)The nurse is establishing outcomes for a client who is depressed. The outcomes will be entered into the nursing care plan and used by all members of the treatment team. The best stated outcome is the client will:
A)Feel less depressed.
B)Decrease score on depression scale by one half.
C)Develop more insight into his problems.
D)Increase amount of time spent with other clients.

ANSWER

9)A client has a continuously running peripheral infusion. The physician orders the addition of a antibiotic as a piggyback infusion four times per day. In order to administer the antibiotic, the nurse should do which of the following?

1. Start a new IV access to administer the antibiotic so that there will not be compatibility issues.
2. Start a new IV access to eliminate the problem of too much volume for one site.
3. Increase the flow rate of the continuous infusion to facilitate the administration of the antibiotic.
4. Check to see if the antibiotic is compatible with the continuous infusion.

ANSWER

8) The nurse has emptied a Jackson Pratt wound-drainage device and needs to reestablish suction to the tube. Which of the following actions should the nurse take to accomplish this objective?

1. Ensure the tubing has no kinks.
2. Squeeze the collection chamber.
3. Wipe the port with alcohol.
4. Close the cap on the device.

ANSWER

7)The client couple is planning intracytoplasmic sperm injection, followed by intrauterine embryo transfer. Which of the following statements indicates that the nurse’s teaching was effective?

1. "His sperm swim too fast for me to become pregnant."
2. "My eggs have thick walls and don’t let his sperm in."
3. "Any extra embryos can be frozen for implantation later."
4. "We will have to wait several weeks to see if any eggs get fertilized."

ANSWER

6)A nurse is preparing to complete an admission assessment on a client that is partially hearing impaired. The best approach would be to do which of the following?

A)Request that family member be present
B)Prepare written questions that cover the assessment criteria
C)Speak slowly in a low-pitched voice while facing the client
D)Perform physical assessment only at this time


ANSWER

5)The physician is planning to wean a patient off a ventilator and asks the nurse for which of the following data important for assessing the patient’s ventilatory status?

A. Echocardiogram
B. Breath sounds
C. Arterial blood gas
D. FiO2 needs of the patient

ANSWER

4) The nurse is assessing a septic patient with hypotension and tachycardia. The nurse reviews the patient's lab results and expects an elevation of:

A. Ammonia
B. Hemoglobin
C. Lactate
D. Platelets

ANSWER

3)A nurse is preparing a blood transfusion for an anemic toddler. Which of the following blood transfusion matches would cause a hemolytic reaction?

A. O-negative blood to a B-negative patientB. A-negative blood to an A-positive patientC. A-positive blood to an AB-negative patientD. B-positive blood to a B-positive patient

ANSWER

2) A 9-year-old diagnosed with leukemia is also being treated for epilepsy. The physician prescribes carbamazepine 100 mg PO twice per day. The nurse should question this order because:

A. This is a lethal dose
B. Carbamazepine is not approved for children
C. Carbamazepine causes bone marrow suppression
D. Carbamazepine is for diabetes

ANSWER

1)A nurse is assessing a patient with acute pancreatitis. The nurse should be aware of which assessment findings that support the diagnosis?

A. Recent weight loss and febrile
B. Hypertension and bruising
C. Wheezes and bradycardia
D. Blood in the patient’s stool and headache

CORRECT ANSWER

                                                Make Me RN Facebook Page



“To laugh often and much, to appreciate beauty, to find the best in others,
to leave the world a bit better, to know that even one life has breathed easier
because you have lived, this is to have succeeded.”
—Ralph Waldo Emerson