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

94) A 53-year-old patient was admitted to the surgical unit after undergoing a right modified radical mastectomy. Which of the following should the nurse include in the patient’s care plan?
A. While assessing the surgical dressing, check the right posterior axilla
B. Withdraw blood samples from the right arm only
C. Make sure the patient is positioned supine with the right arm elevated on a pillow
D. Take the blood pressure in the right arm

ANSWER

93) The nurse is administering a vesicant chemotherapeutic medication intravenously. The nurse should take immediate action if which of the following develops?

A. A rash on the patient’s torso
B. Pain around the infusion site
C. Nausea and dizziness
D. Dry mouth

ANSWER

92) A patient has been diagnosed with renal failure and has spent the last week in the hospital. The patient’s employer calls the unit and asks for the patient’s diagnosis for insurance purposes. How can the nurse best respond?
A. “Of course! Insurance companies can be such a pain!”
B. “He has kidney disease”
C. “I cannot give out information regarding any patient”
D. “Please submit your request in writing”

ANSWER

91) Which of the following assessments made by the nurse could indicate the development of portal hypertension in a client with cirrhosis?
A) Hemorrhoids
B) Bleeding gums
C) Muscle wasting
D) Hypothermia

ANSWER

90) During augmentation of labor with intravenous oxytocin (Pitocin), a multiparous client becomes pale and diaphoretic, and complains of severe lower abdominal pain with a tearing sensation. Fetal distress is noted on the monitor. The nurse should suspect:
A) Precipitate labor.
B) Amniotic fluid embolus.
C) Rupture of the uterus.
D) Uterine prolapse.

ANSWER

89) While a child is receiving prednisone (Deltasone) for treatment of nephrotic syndrome, the nurse determines that it is important to assess the child for:
A) Infection.
B) Urinary retention.
C) Easy bruising.
D) Hypoglycemia.

ANSWER

88) A client diagnosed with cancer who is receiving sargramostim (Leukine) should be instructed to do which of the following?
A) Receive vitamin B6 concurrently.
B) Use good oral hygiene.
C) Expect alopecia.
D) Assess blood glucose levels daily.
ANSWER

87) Which of the following clients is most likely to acquire hepatitis?
A) A child with a bacterial infection
B) A client with dysfunction of the biliary system
C) A client with metastasis of liver cancer
D) An adult with varicella zoster

ANSWER

86) Which item should the nurse plan to omit from the meal tray of the client being treated with theophylline (Theo-Dur)?
A) Peas
B) Beans
C) Milk
D) Coffee

ANSWER

85) The school nurse is planning a community education program about childhood mental health problems that appear to be genetically transmitted. While conducting the program, the nurse will emphasize information about which problem?
A) Anxiety states
B) Sleepwalking
C) Enuresis
D) Oppositional defiance disorder (ODD)

ANSWER

84) The labor and delivery nurse performs Leopold’s maneuvers. A soft round mass is

felt in the fundal region. A flat object is noted on the left and small objects are noted

on the right of the uterus. A hard round mass is noted above the symphysis. Which

of the following positions is consistent with these findings?

1. Left occipital anterior (LOA).

2. Left sacral posterior (LSP).

3. Right mentum anterior (RMA).

4. Right sacral posterior (RSP).

ANSWER

83) A child is treated with edetate calcium disodium (Calcium EDTA) for lead poisoning. Which of the following must the nurse assess FIRST?
 A)  Serum potassium level
 B)  Blood calcium level
 C)  Urinary output
 D)  Deep tendon reflexes

ANSWER

82) To prevent keratitis in an unconscious client, the nurse should apply moisturizing ointment to the
 A)  Finger and toenail quicks
 B)  Eyes
 C)  Perianal area
 D)  External ear canals


ANSWER

81) The nurse is assessing a 17 year-old female client with bulimia. Which of the following laboratory reports would the nurse anticipate?
 A)  Increased serum glucose
 B)  Decreased albumin
 C)  Decreased potassium
 D)  Increased sodium retention

ANSWER

80) The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is CRITICAL for the nurse to include in the plan of care?
 A)  Hourly urine output
 B)  White blood count
 C)  Blood glucose every four hours
 D)  Temperature every two hours

ANSWER

79) A nurse is working with family members of a newly diagnosed client with Alzheimer's disease. Which of the following interventions is MOST helpful?
 A)  Teaching relaxation techniques
 B)  Implementing a daily exercise routine
 C)  Improving daily nutritional intake
 D)  Suggesting communication strategies

ANSWER

78) The nurse enters the client’s room and realizes the 9-month-old infant is not breathing.
Which interventions should the nurse implement? Prioritize the nurse’s actions
from first (1) to last (5).
1. Perform cardiac compression 30:2.
2. Check the infant’s brachial pulse.
3. Administer two puffs to the infant.
4. Determine unresponsiveness.
5. Open the infant’s airway.

ANSWER

77) A client with herpes zoster infection (shingles) has started therapy with acyclovir (Zovirax). The nurse performs what important intervention during the course of this treatment?

A) Monitors for jaundice and elevated liver enzymes.

B) Teaches the client to avoid sexual intercourse during therapy.

C) Administers the dose early in the day, as it could cause insomnia.

D) Encourages fluid intake of 2,500-3,000 mL daily, since it is not contraindicated by other client conditions.

ANSWER

76) Which of the following measures should the nurse focus on in the client with esophageal varices who is scheduled to undergo sclerotherapy?

A) Recognizing hemorrhage

B) Controlling blood pressure

C) Encouraging nutritional intake

D) Teaching the client about varices

ANSWER

75) The nurse is teaching a client about cromolyn (Intal). Which of the following statements should the nurse make about the mechanism of action of this medication?

A) "Cromolyn relaxes bronchial smooth muscle, to assist with bronchodilation."

B) "Cromolyn limits inflammation, and therefore bronchoconstriction, with exposure to an allergen."

C) "Cromolyn helps to liquefy secretions to promote expectoration."

D) "Cromolyn promotes bronchoconstriction of overly dilated airways."

ANSWER

74) A nurse has selected a transparent film dressing for a stage 2 pressure ulcer. The nurse will change the dressing

A) every 8 hours.

B) every 72 hours.

C) when the edges roll up and exudate leaks.

D) when there is a change in color.

ANSWER

73) A male client has been diagnosed with acute diarrhea. He is allergic to aspirin (ASA), and takes no medications. Which antidiarrheal medication should not be given to this client?

A) Lomotil

B) Pepto-Bismol

C) Kaopectate

D) Imodium

ANSWER

72) A 25-year-old male patient presents to the emergency department with report of an extremely severe, unilateral, burning pain located behind the eyes. The patient denies any nausea, vomiting, aura, or chills. Some alternative therapies used by the patient to treat the pain include vitamin D, elemental calcium, riboflavin (vitamin B), acupuncture, relaxation, massage, and osteopathic manipulation. Which type of headache does this most closely resemble in this patient?
a. tension headache
b. common headache
c. cluster headache
d. classic migraine

ANSWER

71) After receiving an oral dose of codeine for an intractable cough, the client asks the nurse, "How long will it take for this drug to work?" How should the nurse respond?

A. In 30 minutes

B. In 1 hour

C. In 2.5 hours

D. In 4 hours

ANSWER 

70) When preparing a client, age 50, for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?

A.Obstruction of the appendix may increase venous drainage and cause the appendix to rupture.

B.Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix.

C.The appendix may develop gangrene and rupture, especially in a middle-aged client.

D.Infection of the appendix diminishes necrotic arterial blood flow and increases venous drainage.

ANSWER 

69) A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a complication of this condition?
A) Dyspnea
B) Heart murmur
C) Macular rash
D) Hemorrhage


ANSWER

68) A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action
A) May result in charges of unlawful seclusion and restraint
B) Leaves the nurse vulnerable for charges of assault and battery
C) Was appropriate in view of the client's history of violence
D) Was necessary to maintain the therapeutic milieu of the unit

ANSWER

67) Small air bubbles adhering to the interior surface of the syringe might have which effect with parenteral administration?
A.Altered onset of action
B.Altered duration
C.Altered drug absorption
D.Altered drug dose

ANSWER

66) A 45-year-old male asks the nurse to assess several spots that have suddenly appeared. They are large, smooth, velvety, and brown. The nurse determines that these are characteristic of which of the following conditions?
A) Lentigo
B) Squamous cell carcinoma
C) Seborrheic keratosis
D) Melanoma

ANSWER

65) The nurse has admitted a client with uremia. The nurse plans care for which of the following underlying disorders?
A) Polycystic kidney disease
B) End-stage renal failure
C) Pyelonephritis
D) Cystitis

ANSWER

64) A client who admits to crack cocaine use during her pregnancy asks the nurse not to inform the baby’s father about the substance abuse. Which response by the nurse is most appropriate?
A) "You must be very worried about how he will react to that information."
B) "This is your pregnancy and your body, so I’ll keep your information private."
C) "Your baby will probably not survive, so there is no need for him to know."
D) "Have you considered that he deserves to know what you may have done to his baby?"

ANSWER

63) A female client is considering in vitro fertilization and gamete intrafallopian transfer (GIFT). Which of the following statements indicates that she needs additional information?
A) "I will give myself injections of medications to cause my ovaries to ripen more than one egg."
B) "My husband will need to produce a sample of his sperm the day my eggs are retrieved."
C) "I will be in the hospital overnight for this procedure."
D) "I can expect to have some discomfort after the procedure."


ANSWER

62) The client who has esophageal varices is receiving a vasopressin infusion. Which of these findings would indicate a complication of this therapy?
A) Chest pain
B) Tinnitus
C) Flushed skin
D) Polyuria

ANSWER

61)A patient is brought into the emergency department with a pheochromocytoma. In order to reverse the lethal symptoms of this disease, the nurse prepares to infuse:

A. Norepinephrine
B. Atropine
C. Dopamine
D. Phenoxybenzamine

ANSWER

60) A 21-year-old male college student has become increasingly suspicious of his professor and fellow classmates. He has accused the professor of conspiring with two other classmates to get him expelled from school. The client is admitted to a psychiatric unit after telephoning and threatening to kill the professor and his classmates. The client tells the nurse, "They are all out to get me expelled. I think they are even trying to kill me. I have to stop them." What would be the most appropriate response by the nurse?
A) "What makes you think they are out to get you expelled or to kill you?"
B) "I find it hard to believe that your professor and classmates are out to get you expelled or to kill you."
C) "It's not right to kill others even if they are out to get you expelled or want to kill you."
D) "Your professor and classmates are not out to get you expelled or to kill you. Let's look at the facts."

ANSWER

59) The client who has peripheral edema during the day states he wakes up in bed at night with difficulty breathing. Which of the following is he most likely experiencing?
A) Angina pectoris
B) Orthopnea caused by recumbent position
C) A sinus infection
D) Sleep apnea

ANSWER

58) A 78-year-old client is admitted with dehydration and urinary tract infection. After IV infusion of 750 mL NS, the client begins to cough, and asks for the head of the bed to be raised to ease breathing. The nurse assesses jugular vein distention (JVD) and increased respiratory rate. The nurse interprets that:
A) The fluid volume deficit is worsening.
B) Hypervolemia is developing.
C) Hypotonic water intoxication is beginning.
D) Ascites is causing respiratory compromise.

ANSWER

57) A child with a brain tumor has shown symptoms of diabetes insipidus. A nursing assessment to monitor this condition would include
A) Blood glucose levels.
B) Urine specific gravity.
C) Adrenocorticotropic hormone (ACTH) levels.
D) Blood urea nitrogen (BUN) levels.

ANSWER

56)The nurse is preparing a care plan for a patient with ascites related to cirrhosis. Which of the following nursing diagnoses should take priority?

A. Excess fluid volume
B. Ineffective breathing pattern
C. Nutritional deficiency
D. Risk of poisoning

ANSWER

55) The nurse is caring for several children with burn injuries. The nurse determines that it is most important to check the pedal pulses in a child with:
A) A full-thickness burn to the medial aspect of the left thigh.
B) A full thickness burn to the posterior of the right leg.
C) A circumferential burn to the upper half of the right lower leg.
D) Partial and full thickness burns to the upper thigh of the left leg.

ANSWER

54) A charge nurse is determining to which nurse to delegate the care of a postoperative client who had a transurethral resection of the prostate (TURP). What element of delegation should the charge nurse consider when making this assignment?
A) Comprehension of the task
B) Time management skills
C) Feedback from the charge nurse
D) The experience of the nurse

ANSWER

53)The stroke patient asked the nurse regarding the difference between a cerebrovascular accident (CVA) and a transient ischemic attack (TIA). The nurse correctly says:

A. TIA is permanent with long-term focal deficits
B. There is spontaneous resolution of the neurologic deficit in a TIA
C. In a TIA, there is intermittent but permanent motor and sensory deficits
D. TIA does not have long-term neurologic deficits although it is a permanent disability

ANSWER

52) When caring for a client who has a potassium level of 2.8 mEq/L, the nurse should assess for which of the following?
A) Perforated bowel
B) Paralytic ileus
C) Renal failure
D) Diabetes mellitus

ANSWER

51) Which of the following nursing interventions is contraindicated in the care of a client with acute osteomyelitis?
A) Apply heat compresses to the affected area
B) Immobilize the affected area
C) Administer narcotic analgesics for pain
D) Administer OTC analgesics for pain

ANSWER

50) 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

49)The nurse is administering an ACTH stimulation test to a patient suspected of having Addison’s disease. Which of the following is true regarding the ACTH stimulation test?

A. Blood is drawn 12 hours after ACTH administration
B. Blood is drawn at baseline, 30 minutes and 60 minutes after ACTH administration
C. Blood is drawn at baseline and 12 hours after ACTH administration
D. Blood is drawn at baseline and 6 hours after ACTH administration

ANSWER

48) The rationale for the nurse to ensure that a client gives informed consent for contraception prior to use is based on knowledge that contraceptive methods:
A) Are invasive procedures.
B) Require a surgical procedure.
C) May not be reliable.
D) Have potentially dangerous side effects.

ANSWER

47) A nurse is gathering health history information from a newly admitted patient. The patient denies any known diseases but gives the nurse a bottle of gemfibrozil that she has been taking for one year. The nurse should question the patient about the presence of what disease?

A. Hypertension
B. Atrial fibrillation
C. Hyperlipidemia
D. Type 2 diabetes

ANSWER

46) The nurse is preparing to inspect the turbinates of a client. What piece of equipment would the nurse select that is necessary for this part of the assessment?
A) Ear speculum
B) Laryngoscope
C) Nasal speculum
D) Otoscope

ANSWER

45) The nurse determines that a male client needs additional teaching about an upcoming varicocele repair surgery when he states:
A) "My sperm count should rise after the procedure."
B) "I'll have fewer sperm that swim after the procedure."
C) "I'll have fewer sperm but more with normal shape."
D) "I may have erection problems, but more sperm."

ANSWER

44) Which of the following clients is at highest risk of experiencing a spontaneous pneumothorax?
A) A client who is homeless, HIV-positive, and lives in an overcrowded alley
B) A client who is obese, elderly, and a chronic smoker
C) A tall, thin young man who smokes
D) A 35-year-old woman who smokes and is overweight

ANSWER

43) 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

42)A 5-year-old with severe osteomyelitis has not been responding to first line therapy. The nurse is ordered to initiate vancomycin I.V. every 6 hours to the patient. If the recommended dose is 10 mg/kg, what is the total daily dose of vancomycin if the patient weighs 44 lbs?

A. 440 mg
B. 800 mg
C. 200 mg
D. 888 mg

ANSWER

41) A 40-year-old, G7, P4, A2, 36 weeks pregnant was admitted because of complaints of vaginal bleeding. She also noticed a lack of fetal activity in the 3 days prior to admission. The nurse’s first ac-tion is to:
A. Check for fetal heart tones
B. Ask for ultrasound examination
C. Ask for X-ray of the abdomen
D. Palpate for fetal movement

ANSWER

40) A nurse is making rounds after receiving report. The nurse observes the client is receiving the wrong intravenous fluid. What is the nurse’s next action?

A) Write an incident report, and submit it to the manager.

B) Replace the bag of fluid with the fluid that was ordered.

C) Report the incident to the charge nurse and the physician.

D) Replace the fluid, and discuss the error with other staff nurses


ANSWER

39) A client asks why a diagnostic test has been ordered and the nurse replies, "I’m unsure but will find out for you." When the nurse later returns and provides an explanation, the nurse is acting under which principle?
A) Nonmaleficence
B) Veracity
C) Beneficence
D) Fidelity

ANSWER

38) The nurse anticipates that which of the following treatments would be used for a client who has a magnesium level of 2.5 mEq/L?
A) Magnesium oxide (MagOx)
B) Furosemide (Lasix)
C) Calcium carbonate (TUMS)
D) Fluid restriction

ANSWER

37) A patient has requested an oral contraceptive to reduce the risk of pregnancy. The physician prescribes ethinyl estradiol 30-drospirenone 3 to be cycled for 21 days and followed by a 7 day break. Which classification of contraceptive is ethinyl estradiol 30-drospirenone 3?

A. Multiphasic
B. Implant
C. Monophasic
D. Extended cycle

ANSWER