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101. Which observation would the nurse expect to make after an amniotomy?   

❍ A.  Dark yellow amniotic fluid   

❍ B.  Clear amniotic fluid   

❍ C.  Greenish amniotic fluid   ❍ D.  Red amniotic fluid   



102. The client taking Glyburide (Diabeta) should be cautioned to:   ❍ A.  Avoid eating sweets   ❍ B.  Report changes in urinary pattern   

❍ C.  Allow 3 hours for onset   
❍ D.  Check the glucose daily   




103. The obstetric client’s fetal heart rate is 80–90 during the contractions. The first action the nurse should take is:   

❍ A.  Reposition the monitor   

❍ B.  Turn the client to her left side   

❍ C.  Ask the client to ambulate   
❍ D.  Prepare the client for delivery   




104. Arterial ulcers are best described as ulcers that:

❍ A.Are smooth in texture   

❍ B.Have irregular borders   

❍ C.Are cool to touch   

❍ D.Are painful to touch




105. A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time? 

❍ A.  Anticipate the need for a Caesarean section   

❍ B.  Apply an internal fetal monitor   

❍ C.  Place the client in Genu Pectoral position   

❍ D.  Perform an ultrasound   







106. A vaginal exam reveals thatthe cervix is 4cm dilated, with intact mem-branes and a fetal heart tone rate of 160–170bpm. The nurse decides to apply an external fetal monitor. The rationale for this implementation is:   

❍ A.  The cervix is closed.   

❍ B.  The membranes are still intact.   

❍ C.  The fetal heart tones are within normal limits.   

❍ D. The contractions are intense enough for insertion of an inter-nal monitor.   







107. The following are all nursing diagnoses appropriate for a gravida 1 para 0 in labor. Which one would be most appropriate for the primagravida as she completes the early phase of labor?  

❍ A.  Impaired gas exchange related to hyperventilation   


❍ B.  Alteration in placental perfusion related to maternal position   


❍ C. Impaired physical mobility related to fetal-monitoring equip-ment   


❍ D.  Potential fluid volume deficit related to decreased fluid intake  





 108. As the client reaches 6cm dilation, the nurse notes late decelerations on the fetal monitor. What is the most likely explanation of this pattern?

❍ A.  The baby is sleeping.   

❍ B.  The umbilical cord is compressed.   

❍ C.  There is head compression.   

❍ D.  There is uteroplacental insufficiency.  





109. The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:   

❍ A.  Notify her doctor   

❍ B.  Start an IV   

❍ C.  Reposition the client   

❍ D.  Readjust the monitor   


110. Which of the following is a characteristic of an ominous periodic change in the fetal heart rate?   


❍ A.  A fetal heart rate of 120–130bpm   
❍ B.  A baseline variability of 6–10bpm  
❍ C.  Accelerations in FHR with fetal movement   
❍ D. A recurrent rate of 90–100bpm at the end of the contractions. 



111. The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:  

❍ A. The bladder fills more rapidly because of the medication used for the epidural.   
❍ B. Her level of consciousness is such that she is in a trancelike state.   
❍ C.  The sensation of the bladder filling is diminished or lost.   ❍ D.  She is embarrassed to ask for the bedpan that frequently.  




112. A client in the family planning clinic asks the nurse about the most likely time for her to conceive. The nurse explains that conception is most like-ly to occur when:   


❍ A.  Estrogen levels are low.   
❍ B.  Lutenizing hormone is high. 

❍ C.  The endometrial lining is thin.   ❍ D.  The progesterone level is low.






 113. A client tells the nurse that she plans to use the rhythm method of birth control. The nurse is aware that the success of the rhythm method depends on the: 


❍ A.  Age of the client   
❍ B.  frequency of intercourse   
❍ C.  Regularity of the menses   
❍ D.  Range of the client’s temperature   






114. A client with diabetes asks the nurse for advice regarding methods of birth control. Which method of birth control is most suitable for the client with diabetes?   


❍ A.  Intrauterine device   
❍ B.  Oral contraceptives   
❍ C.  Diaphragm   

❍ D.  Contraceptive sponge   





115. The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a diagnosis of a ruptured ectopic pregnancy?   


❍ A.  Painless vaginal bleeding   

❍ B.  Abdominal cramping   
❍ C.  Throbbing pain in the upper quadrant   
❍ D.  Sudden, stabbing pain in the lower quadrant   



116. The nurse is teaching a pregnant client about nutritional needs during pregnancy. Which menu selection will best meet the nutritional needs of the pregnant client?   



❍ A.  Hamburger pattie, green beans, French fries, and iced tea   


❍ B.  Roast beef sandwich, potato chips, baked beans, and cola   


❍ C. Baked chicken, fruit cup, potato salad, coleslaw, yogurt, and iced tea   ❍ D.  Fish sandwich, gelatin with fruit, and coffee     






117. The client with hyperemesis gravidarum is at risk for developing:   


❍ A.  Respiratory alkalosis without dehydration   ❍ B.  Metabolic acidosis with dehydration   ❍ C.  Respiratory acidosis without dehydration   ❍ D.  Metabolic alkalosis with dehydration  






 118. A client tells the doctor that she is about 20 weeks pregnant. The most definitive sign of pregnancy is:   


❍ A.  Elevated human choronic gonadatropin   ❍ B.  The presence of fetal heart tones   ❍ C.  Uterine enlargement   ❍ D.  Breast enlargement and tenderness   






119. The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to be:   


❍ A.  Hypoglycemic, small for gestational age   ❍ B.  Hyperglycemic, large for gestational age   ❍ C.  Hypoglycemic, large for gestational age   ❍ D.  Hyperglycemic, small for gestational age   






120. Which of the following instructions should be included in the nurse’s teaching regarding oral contraceptives?   


❍ A.  Weight gain should be reported to the physician.   ❍ B. An alternate method of birth control is needed when taking antibiotics.   ❍ C. If the client misses one or more pills, two pills should be taken per day for 1 week.   ❍ D. Changes in the menstrual flow should be reported to the physician.   







121. The nurse is discussing breastfeeding with a postpartum client. Breastfeeding is contraindicated in the postpartum client with:   


❍ A.  Diabetes   ❍ B.  HIV   ❍ C.  Hypertension   ❍ D.  Thyroid disease  






122. A client is admitted to the labor and delivery unit complaining of vaginal bleeding with very little discomfort. The nurse’s first action should be to:   

❍ A.  Assess the fetal heart tones   

❍ B.  Check for cervical dilation   

❍ C.  Check for firmness of the uterus
❍ D.  Obtain a detailed history   







123. A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when: 

  ❍ A.  Her contractions are 2 minutes apart.
❍ B.  She has back pain and a bloody discharge.   ❍ C.  She experiences abdominal pain and frequent urination.   ❍ D.  Her contractions are 5 minutes apart.   





124. The nurse is teaching a group of prenatal clients about the effects of cig-arette smoke on fetal development. Which characteristic is associated with babies born to mothers who smoked during pregnancy?   


❍ A.  Low birth weight   ❍ B.  Large for gestational age   ❍ C.  Preterm birth, but appropriate size for gestation   ❍ D.  Growth retardation in weight and length   





125. The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A negative but whose baby is O positive. To provide postpartum prophylaxis, RhoGam should be administered:   


❍ A.  Within 72 hours of delivery   

❍ B.  Within 1 week of delivery   

❍ C.  Within 2 weeks of delivery   

❍ D.  Within 1 month of delivery   



126. After the physician performs an amniotomy, the nurse’s first action should be to assess the:  


❍ A.  Degree of cervical dilation   

❍ B.  Fetal heart tones   
❍ C.  Client’s vital signs   
❍ D.  Client’s level of discomfort 





127.  A client is admitted to the labor and delivery unit. The nurse performs a   vaginal exam and determines that the client’s cervix is 5cm dilated with 75% effacement. Based on the nurse’s assessment the client is in which      phase of labor? 


❍ A.  Active   
❍ B.  Latent   
❍ C.  Transition   
❍ D.  Early   






128. A newborn with narcotic abstinence syndrome is admitted to the nursery. Nursing care of the newborn should includ 


❍ A.  Teaching the mother to provide tactile stimulation   
❍ B.  Wrapping the newborn snugly in a blanket   
❍ C.  Placing the newborn in the infant seat   
❍ D.  Initiating an early infant-stimulation program   






129.  A client elects to have epidural anesthesia to relieve the discomfort of labor. Following the initiation of epidural anesthesia, the nurse should give priority to:  


❍ A. Checking for cervical dilation  
❍ B. Placing the client in a supine position  
❍ C. Checking the client’s blood pressure  
❍  D.  Obtaining a fetal heart rate 










 130.  The nurse is aware that the best way to prevent post-operative wound infection in the surgical client is to:


❍ A. Administer a prescribed antibiotic  ❍ B. Wash her hands for 2 minutes before care  ❍ C. Wear a mask when providing care  ❍  D.  Ask the client to cover her mouth when she coughs 





 131.  The elderly client is admitted to the emergency room. Which symptom is the client with a fractured hip mo likely to exhibit? 


❍ A. Pain  ❍ B. Disalignment  ❍ C. Cool extremity  ❍ D. Absence of pedal pulses  





132. The nurse knows that a 60-year-old female client’s susceptibility to osteo-porosis is most likely related to:   


❍ A.  Lack of exercise   ❍ B.  Hormonal disturbances   ❍ C.  Lack of calcium   ❍ D.  Genetic predisposition   





133. A 2-year-old is admitted for repair of a fractured femur and is placed in Bryant’s traction. Which finding by the nurse indicates that the traction is working properly?
❍ A.  The infant no longer complains of pain.   ❍ B.  The buttocks are 15° off the bed.   ❍ C.  The legs are suspended in the traction.   ❍ D.  The pins are secured within the pulley.   





134. Which statement is true regarding balanced skeletal traction? Balanced skeletal traction:   


❍ A.  Utilizes a Steinman pin   ❍ B.  Requires that both legs be secured   ❍ C.  Utilizes Kirschner wires   ❍ D.  Is used primarily to heal the fractured hips  






 135. The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery, the nurse should give priority to assessing the:   


❍ A.  Serum collection (Davol) drain   ❍ B.  Client’s pain   
❍ C.  Nutritional status   
❍ D.  Immobilizer   




136. Which statement made by the family member caring for the client with a percutaneous gastrostomy tube indicates understanding of the nurse’s teaching?   


❍ A. ―I must flush the tube with water after feedings and clamp the tube.‖   
❍ B.  ―I must check placement four times per day.
❍ C.  ―I will report to the doctor any signs of indigestion. 
❍ D. ―If my father is unable to swallow, I will discontinue the feed-ing and call the clinic 
  





 137. The nurse is assessing the client with a total knee replacement 2 hours post-operative. Which information requires notification of the doctor?   


❍ A.  Scant bleeding on the dressing.   ❍ B.  Low-grade temperature.   
❍ C.  Hemoglobin of 7gm   
❍ D.  The urinary output has been 120ml during the last hour.   





138. The nurse is caring for the client with a 5-year-old diagnosis of plumbism. Which information in the health history is most likely related to the development of plumbism?   


❍ A.  The client has traveled out of the country in the last   6 months.   
❍ B.  The client’s parents are skilled stained-glass artists.   
❍ C.  The client lives in a house built in 1990.   
❍ D.  The client has several brothers and sisters.   





139. A client with a total hip replacement requires special equipment. Which equipment would assist the client with a total hip replacement with activ-ities of daily living?   


❍ A.  High-seat commode   
❍ B.  Recliner   
❍ C.  TENS unit   
❍ D.  Abduction pillow   





140. An elderly client with an abdominal surgery is admitted to the unit fol-lowing surgery. In anticipation of complications of anesthesia and narcot-ic administration, the nurse should: 

  ❍ A.  Administer oxygen via nasal cannula   
❍ B.  Have narcan (naloxane) available   
❍ C.  Prepare to administer blood products   
❍ D.  Prepare to do cardioresuscitation   




141. Which roommate would be most suitable for the 6-year-old male with a fractured femur in Russell’s traction?   


❍ A.  16-year-old female with scoliosis   
❍ B.  12-year-old male with a fractured femur   
❍ C.  10-year-old male with sarcoma   
❍ D.  6-year-old male with osteomylitis  





 142. A client with osteoarthritis has a prescription for Celebrex (celecoxib). Which instruction should be included in the discharge teaching?   


❍ A.  Take the medication with milk.   ❍ B.  Report chest pain.   
❍ C.  Remain upright after taking for 30 minutes.   
❍ D.  Allow 6 weeks for optimal effects.   





143. A client with a fractured tibia has a plaster-of-Paris cast applied to immo-bilize the fracture. Which action by the nurse indicates understanding of a plaster-of-Paris cast?   The nurse:   

❍ A.  Handles the cast with the fingertips 

❍ B.  Petals the cast   

❍ C.  Dries the cast with a hair dryer   ❍ D.  Allows 24 hours before bearing weight   





144. The teenager with a fiberglass cast asks the nurse if it will be okay to allow his friends to autograph his cast. Which response would be best?   


❍ A.  ―It will be alright for your friends to autograph the cast.  
 ❍ B. ―Because the cast is made of plaster, autographing can weak-en the cast.
❍ C.  ―If they don’t use chalk to autograph, it is okay.
❍ D. ―Autographing or writing on the cast in any form will harm the cast.






145. The nurse is assigned to care for the client with a Steinmen pin. During pin care, she notes that the LPN uses sterile gloves and Q-tips to clean the pin. Which action should the nurse take at this time?
❍ A. Assisting the LPN with opening sterile packages and peroxide   
❍ B.  Telling the LPN that clean gloves are allowed   
❍ C. Telling the LPN that the registered nurse should perform pin care   ❍ D. Asking the LPN to clean the weights and pulleys with peroxide  





 146. A child with scoliosis has a spica cast applied. Which action specific to the spica cast should be taken?   


❍ A.  Check the bowel sounds   
❍ B.  Assess the blood pressure   

❍ C.  Offer pain medication   ❍ D.  Check for swelling   






147. The client with a cervical fracture is placed in traction. Which type of traction will be utilized at the time of discharge?   ❍ A.  Russell’s traction
❍ B.  Buck’s traction   
❍ C.  Halo traction   
❍ D.  Crutchfield tong traction   





148. A client with a total knee replacement has a CPM (continuous passive motion device) applied during the post-operative period. Which state-ment made by the nurse indicates understanding of the CPM machine?   


❍ A. ―Use of the CPM will permit the client to ambulate during the therapy.
❍ B. ―The CPM machine controls should be positioned distal to the site.
❍ C. ―If the client complains of pain during the therapy, I will turn off the machine and call the doctor.
❍ D.  ―Use of the CPM machine will alleviate the need for   physical therapy after the client is discharged.





149. A client with a fractured hip is being taught correct use of the walker. The nurse is aware that the correct use of the walker is achieved if the:   


❍ A.  Palms rest lightly on the handles   
❍ B.  Elbows are flexed 0°   
❍ C.  Client walks to the front of the walker   
❍ D.  Client carries the walker 





  150. When assessing a laboring client, the nurse finds a prolapsed cord. The nurse should:   


❍ A.  Attempt to replace the cord   

❍ B.  Place the client on her left side   
❍ C.  Elevate the client’s hips   
❍ D.  Cover the cord with a dry, sterile gauze   




151. The nurse is caring for a 30-year-old male admitted with a stab wound. While in the emergency room, a chest tube is inserted. Which of the fol-lowing explains the primary rationale for insertion of chest tubes?   


❍ A.  The tube will allow for equalization of the lung expansion.   ❍ B. Chest tubes serve as a method of draining blood and serous fluid and assist in reinflating the lungs.   ❍ C.  Chest tubes relieve pain associated with a collapsed lung.   

❍ D. Chest tubes assist with cardiac function by stabilizing lung expansion.   






152. A client who delivered this morning tells the nurse that she plans to breastfeed her baby. The nurse is aware that successful breastfeeding is most dependent on the:   
❍ A.  Mother’s educational level   

❍ B.  Infant’s birth weight   
❍ C.  Size of the mother’s breast   

❍ D.  Mother’s desire to breastfeed   





153. The nurse is monitoring the progress of a client in labor. Which finding should be reported to the physician immediately?   


❍ A.  The presence of scant bloody discharge   
❍ B.  frequent urination   
❍ C.  The presence of green-tinged amniotic fluid   
❍ D.  Moderate uterine contractions  





154. The nurse is measuring the duration of the client’s contractions. Which statement is true regarding the measurement of the duration of contrac-tions?  

 ❍ A. Duration is measured by timing from the beginning of one contraction to the beginning of the next contraction.
❍ B. Duration is measured by timing from the end of one contrac-tion to the beginning of the next contraction.   
❍ C. Duration is measured by timing from the beginning of one contraction to the end of the same contraction.   
❍ D. Duration is measured by timing from the peak of one con-traction to the end of the same contraction.   






155. The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intra-venous Pitocin, the nurse should monitor for:   


❍ A.  Maternal hypoglycemia   
❍ B.  Fetal bradycardia   
❍ C.  Maternal hyperreflexia   
❍ D.  Fetal movement   





156. A client with diabetes visits the prenatal clinic at 28 weeks gestation. Which statement is true regarding insulin needs during pregnancy?   


❍ A.  Insulin requirements moderate as the pregnancy progresses.   
❍ B. A decreased need for insulin occurs during the second trimester.   
❍ C. Elevations in human choronic gonadotrophin decrease the need for insulin.   ❍ D.  Fetal development depends on adequate insulin regulation.   





157. A client in the prenatal clinic is assessed to have a blood pressure of 180/96. The nurse should give priority to:   


❍ A.  Providing a calm environment   
❍ B.  Obtaining a diet history   
❍ C.  Administering an analgesic   

❍ D.  Assessing fetal heart tones  





158. A primigravida, age 42, is 6 weeks pregnant. Based on the client’s age, her infant is at risk for:   


❍ A.  Down syndrome   
❍ B.  Respiratory distress syndrome   
❍ C.  Turner’s syndrome   
❍ D.  Pathological jaundice   





159. A client with a missed abortion at 29 weeks gestation is admitted to the hospital. The client will most likely be treated with:   


❍ A.  Magnesium sulfate   
❍ B.  Calcium gluconate   
❍ C.  Dinoprostone (Prostin E.)   
❍ D.  Bromocrystine (Parlodel)   





160. A client with preeclampsia has been receiving an infusion containing magnesium sulfate for a blood pressure that is 160/80; deep tendon reflexes are 1 plus, and the urinary output for the past hour is 100mL. The nurse should:   


❍ A. Continue the infusion of magnesium sulfate while monitoring the client’s blood pressure   
❍ B. Stop the infusion of magnesium sulfate and contact the physician   
❍ C.  Slow the infusion rate and turn the client on her left side   
❍ D. Administer calcium gluconate IV push and continue to moni-tor the blood pressure   





161. Which statement made by the nurse describes the inheritance pattern of autosomal recessive disorders?   


❍ A.  An affected newborn has unaffected parents.   ❍ B.  An affected newborn has one affected parent.   ❍ C. Affected parents have a one in four chance of passing on the defective gene.   ❍ D.  Affected parents have unaffected children who are carriers.   





162. A pregnant client, age 32, asks the nurse why her doctor has recom-mended a serum alpha fetoprotein. The nurse should explain that the doctor has recommended the test:   


❍ A.  Because it is a state law   ❍ B.  To detect cardiovascular defects   ❍ C.  Because of her age   ❍ D.  To detect neurological defects 





 163. A client with hypothyroidism asks the nurse if she will still need to take thyroid medication during the pregnancy. The nurse’s response is based on the knowledge that:   


❍ A. There is no need to take thyroid medication because the fetus’s thyroid produces a thyroid-stimulating hormone.   ❍ B. Regulation of thyroid medication is more difficult because the thyroid gland increases in size during pregnancy.

❍ C. It is more difficult to maintain thyroid regulation during preg-nancy due to a slowing of metabolism.   

❍ D. Fetal growth is arrested if thyroid medication is continued during pregnancy.



164. The nurse is responsible for performing a neonatal assessment on a full-term infant. At 1 minute, the nurse could expect to find:   


❍ A.  An apical pulse of 100   ❍ B.  An absence of tonus   ❍ C.  Cyanosis of the feet and hands   ❍ D.  Jaundice of the skin and sclera  




 165. A client with sickle cell anemia is admitted to the labor and delivery unit during the first phase of labor. The nurse should anticipate the client’s need for:  

 ❍ A.  Supplemental oxygen
❍ B.  Fluid restriction   ❍ C.  Blood transfusion   ❍ D.  Delivery by Caesarean section   





166. A client with diabetes has an order for ultrasonography. Preparation for an ultrasound includes:   


❍ A.  Increasing fluid intake   ❍ B.  Limiting ambulation   ❍ C.  Administering an enema   ❍ D.  Withholding food for 8 hours   





167. An infant who weighs 8 pounds at birth would be expected to weigh how many pounds at 1 year?   


❍ A.  14 pounds   ❍ B.  16 pounds   ❍ C.  18 pounds   ❍ D.  24 pounds




168.  A pregnant client with a history of alcohol addiction is scheduled for a nonstress test. The nonstress test: 


❍ A.  Determines the lung maturity of the fetus   ❍ B.  Measures the activity of the fetus   ❍ C.  Shows the effect of contractions on the fetal heart rate   ❍ D.  Measures the neurological well-being of the fetus   




169. A full-term male has hypospadias. Which statement describes hypospadias?  


❍ A. The urethral opening is absent. ❍ B. The urethra opens on the top side of the penis.   ❍ C. The urethral opening is enlarged.   ❍  D.  The urethra opens on the under side of the penis.   





170.  A gravida III para II is admitted to the labor unit. Vaginal exam reveals that the client’s cervix is 8cm dilated, with complete effacement priority  nursing diagnosis at this time is:  

  ❍ A.  Alteration in coping related to pain   ❍ B.  Potential for injury related to precipitate delivery   ❍ C.  Alteration in elimination related to anesthesia   ❍ D.  Potential for fluid volume deficit related to NPO status





171.  The client with varicella will most likely have an order for which category of medication? 


 ❍ A. Antibiotics  
❍ B. Antipyretics  
❍ C. Antivirals  
❍ D.  Anticoagulants 



 172.  A client is admitted complaining of chest pain. Which of the following drug orders should the nurse question? 


❍ A. Nitroglycerin  
❍ B. Ampicillin  
❍ C. Propranolol  ❍ D.  Verapamil  








173.  Which of the following instructions should be included in the teaching for the client with rheumatoid arthritis?  



❍ A. Avoid exercise because it fatigues the joints.  ❍ B. Take prescribed anti-inflammatory medications with meals.  ❍ C. Alternate hot and cold packs to affected joints.  ❍ D. Avoid weight-bearing activity. 








174. A client with acute pancreatitis is experiencing severe abdominal pain. Which of the following orders should be questioned by the nurse?   


❍ A.  Meperidine 100mg IM m 4 hours PRN pain   ❍ B.  Mylanta 30 ccs m 4 hours via NG   ❍ C.  Cimetadine 300mg PO m.i.d. 

❍ D.  Morphine 8mg IM m 4 hours PRN pain   





175. The client is admitted to the chemical dependence unit with an order for continuous observation. The nurse is aware that the doctor has ordered continuous observation because:   

❍ A. Hallucinogenic drugs create both stimulant and depressant effects.
❍ B.  Hallucinogenic drugs induce a state of altered perception.   ❍ C.  Hallucinogenic drugs produce severe respiratory depression.   ❍ D.  Hallucinogenic drugs induce rapid physical dependence.   






176. A client with a history of abusing barbiturates abruptly stops taking the medication. The nurse should give priority to assessing the client for:  


❍ A.  Depression and suicidal ideation   ❍ B.  Tachycardia and diarrhea   

❍ C.  Muscle cramping and abdominal pain   ❍ D.  Tachycardia and euphoric mood   





177. During the assessment of a laboring client, the nurse notes that the FHT are loudest in the upper-right quadrant. The infant is most likely in which position?  

 ❍ A.  Right breech presentation   

❍ B.  Right occipital anterior presentation
❍ C.  Left sacral anterior presentation   ❍ D.  Left occipital transverse presentation   





178. The primary physiological alteration in the development of asthma is:   


❍ A.  Bronchiolar inflammation and dyspnea   

❍ B.  Hypersecretion of abnormally viscous mucus   

❍ C.  Infectious processes causing mucosal edema   

❍ D.  Spasm of bronchiolar smooth muscle  






 179. A client with mania is unable to finish her dinner. To help her maintain sufficient nourishment, the nurse should:   


❍ A.  Serve high-calorie foods she can carry with her   

❍ B.  Encourage her appetite by sending out for her favorite foods

❍ C.  Serve her small, attractively arranged portions   

❍ D. Allow her in the unit kitchen for extra food whenever she pleases   






180. To maintain Bryant’s traction, the nurse must make certain that the child’s:   


❍ A. Hips are resting on the bed, with the legs suspended at a right angle to the bed   

❍ B. Hips are slightly elevated above the bed and the legs are sus-pended at a right angle to the bed   

❍ C. Hips are elevated above the level of the body on a pillow and the legs are suspended parallel to the bed   

❍ D. Hips and legs are flat on the bed, with the traction positioned at the foot of the bed   







181. Which action by the nurse indicates understanding of herpes zoster?   


❍ A.  The nurse covers the lesions with a sterile dressing.   
❍ B.  The nurse wears gloves when providing care.   
❍ C.  The nurse administers a prescribed antibiotic.   
❍ D.  The nurse administers oxygen.   





182. The client has an order for a trough to be drawn on the client receiving Vancomycin. The nurse is aware that the nurse should contact the lab for them to collect the blood:   


❍ A.  15 minutes after the infusion   
❍ B.  30 minutes before the fourth infusion   
❍ C.  1 hour after the infusion   
❍ D.  2 hours after the infusion   





183. The client using a diaphragm should be instructed to:   


❍ A.  Refrain from keeping the diaphragm in longer than 4 hours
❍ B.  Keep the diaphragm in a cool location   
❍ C.  Have the diaphragm resized if she gains 5 pounds   
❍ D.  Have the diaphragm resized if she has any surgery 




184. The nurse is providing postpartum teaching for a mother planning to breastfeed her infant. Which of the client’s statements indicates the need for additional teaching? 


❍ A.  ―I’m wearing a support bra.‖   
❍ B.  ―I’m expressing milk from my breast.‖   
❍ C.  ―I’m drinking four glasses of fluid during a 24-hour period.‖ 

❍ D. ―While I’m in the shower, I’ll allow the water to run over my breasts.‖   














185. Damage to the VII cranial nerve results in:   


❍ A.  Facial pain   

❍ B.  Absence of ability to smell   

❍ C.  Absence of eye movement   

❍ D.  Tinnitus   





186. A client is receiving Pyridium (phenazopyridine hydrochloride) for a uri-nary tract infection. The client should be taught that the medication may:   


❍ A.  Cause diarrhea   

❍ B.  Change the color of her urine   ❍ C.  Cause mental confusion   

❍ D.  Cause changes in taste   






187. Which of the following tests should be performed before beginning a prescription of Accutane?   


❍ A.  Check the calcium level   

❍ B.  Perform a pregnancy test   

❍ C.  Monitor apical pulse   

❍ D.  Obtain a creatinine level   




188. A client with AIDS is taking Zovirax (acyclovir). Which nursing interven-tion is most critical during the administration of acyclovir?   


❍ A.  Limit the client’s activity   

❍ B.  Encourage a high-carbohydrate diet   

❍ C. Utilize an incentive spirometer to improve respiratory function   

❍ D.  Encourage fluids  





189. A client is admitted for an CAT scan. The nurse should question the client regarding:  


❍ A.  Pregnancy   

❍ B.  A titanium hip replacement 

❍ C.  Allergies to antibiotics   

❍ D.  Inability to move his feet   





190. The nurse is caring for the client receiving Amphotericin B. Which of the following indicates that the client has experienced toxicity to this drug?   


❍ A.  Changes in vision   

❍ B.  Nausea   

❍ C.  Urinary frequency   

❍ D.  Changes in skin color   






191. The nurse should visit which of the following clients first?  


❍ A.  The client with diabetes with a blood glucose of 95mg/dL   

❍ B.  The client with hypertension being maintained on Lisinopril   

❍ C.  The client with chest pain and a history of angina   

❍ D.  The client with Raynaud’s disease   






192. A client with cystic fibrosis is taking pancreatic enzymes. The nurse should administer this medication:   


❍ A.  Once per day in the morning   ❍ B.  Three times per day with meals   ❍ C.  Once per day at bedtime   ❍ D.  Four times per day   












193. Cataracts result in opacity of the crystalline lens. Which of the following best explains the functions of the lens?   


❍ A.  The lens controls stimulation of the retina.   ❍ B.  The lens orchestrates eye movement.   ❍ C.  The lens focuses light rays on the retina.   ❍ D.  The lens magnifies small objects.   






194. A client who has glaucoma is to have miotic eyedrops instilled in both eyes. The nurse knows that the purpose of the medication is to:   


❍ A.  Anesthetize the cornea   ❍ B.  Dilate the pupils   ❍ C.  Constrict the pupils   ❍ D.  Paralyze the muscles of accommodation  





 195. A client with a severe corneal ulcer has an order for Gentamycin gtt. q 4 hours and Neomycin 1 gtt q 4 hours. Which of the following schedules should be used when administering the drops?   


❍ A.  Allow 5 minutes between the two medications.   ❍ B.  The medications may be used together.   ❍ C.  The medications should be separated by a cycloplegic drug.   ❍ D.  The medications should not be used in the same client.   





196. The client with color blindness will most likely have problems distin-guishing which of the following colors?   


❍ A.  Orange   ❍ B.  Violet   ❍ C.  Red   ❍ D.  White   





197. The client with a pacemaker should be taught to:
❍ A.  Report ankle edema   ❍ B.  Check his blood pressure daily   ❍ C.  Refrain from using a microwave oven   ❍ D.  Monitor his pulse rate   




198. The client with enuresis is being taught regarding bladder retraining. The nurse should advise the client to refrain from drinking after:   


❍ A.  1900   
❍ B.  1200   
❍ C.  1000   
❍ D.  0700   





199. Which of the following diet instructions should be given to the client with recurring urinary tract infections?   


❍ A.  Increase intake of meats.   

❍ B.  Avoid citrus fruits.   
❍ C.  Perform pericare with hydrogen peroxide.   
❍ D.  Drink a glass of cranberry juice every day. 



200. The physician has prescribed NPH insulin for a client with diabetes melli-tus. Which statement indicates that the client knows when the peak action of the insulin occurs?   


❍ A. ―I will make sure I eat breakfast within 2 hours of taking my insulin.

❍ B. ―I will need to carry candy or some form of sugar with me all the time. 

❍ C.  ―I will eat a snack around three o’clock each afternoon.  

❍ D.  ―I can save my dessert from supper for a bedtime snack 









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