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