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📋Answers OF These Practice Questions are given at the End of Questions 

1. A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extrem-ities every 2 hours. Which of the following outcome criteria would the nurse use?   

❍ A.  Body temperature of 99°F or less   

❍ B.  Toes moved in active range of motion   

❍ C.  Sensation reported when soles of feet are touched   

❍ D.  Capillary refill of < 3 seconds   

2. A 30-year-old male from Haiti is brought to the emergency depart-ment in sickle cell crisis. What is the best position for this client?   

❍ A.  Side-lying with knees flexed 

❍ B.  Knee-chest   

❍ C.  High Fowler’s with knees flexed   

❍ D.  Semi-Fowler’s with legs extended on the bed   

3. A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?   

❍ A.  Taking hourly blood pressures with mechanical cuff   

❍ B.  Encouraging fluid intake of at least 200mL per hour   

❍ C.  Position in high Fowler’s with knee gatch raised   

❍ D.  Administering Tylenol as ordered   

4. Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?   

❍ A.  Peaches   

❍ B.  Cottage cheese   

❍ C.  Popsicle   

❍ D.  Lima beans 

5. A newly admitted client has sickle cell crisis. He is complaining of pain in his feet and hands. The nurse’s assessment findings include a pulse oximetry of 92. Assuming that all the following interventions are ordered, which should be done first?   

❍ A.  Adjust the room temperature   

❍ B.  Give a bolus of IV fluids   

❍ C.  Start O2   

❍ D.  Administer meperidine (Demerol) 75mg IV push   

6. The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select?   

❍ A.  Roast beef, gelatin salad, green beans, and peach pie   

❍ B.  Chicken salad sandwich, coleslaw, French fries, ice cream   

❍ C. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie   

❍ D.  Pork chop, creamed potatoes, corn, and coconut cake   

7. Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?   

❍ A.  A family vacation in the Rocky Mountains   

❍ B.  Chaperoning the local boys club on a snow-skiing trip   

❍ C.  Traveling by airplane for business trips   

❍ D.  A bus trip to the Museum of Natural History   

8. The nurse is conducting an admission assessment of a client with vita-min B12 deficiency. Which finding reinforces the diagnosis of B12 defi-ciency?   

❍ A.  Enlarged spleen   

❍ B.  Elevated blood pressure   

❍ C.  Bradycardia   

❍ D.  Beefy tongue   

9. The body part that would most likely display jaundice in the dark-skinned individual is the:   

❍ A.  Conjunctiva of the eye   

❍ B.  Soles of the feet   

❍ C.  Roof of the mouth   

❍ D.  Shins    

10. The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?   

❍ A.  BP 146/88   

❍ B.  Respirations 28 shallow   

❍ C.  Weight gain of 10 pounds in 6 months   

❍ D.  Pink complexion   

11. The nurse is teaching the client with polycythemia vera about prevention of complications of the disease. Which of the following statements by the client indicates a need for further teaching?   

❍ A.  ―I will drink 500mL of fluid or less each day.

❍ B.  ―I will wear support hose.

❍ C.  ―I will check my blood pressure regularly 

❍ D.  ―I will report ankle edema.

12. A 33-year-old male is being evaluated for possible acute leukemia. Which of the following findings is most likely related to the diagnosis of leukemia?   

❍ A.  The client collects stamps as a hobby.   

❍ B.  The client recently lost his job as a postal worker.   

❍ C. The client had radiation for treatment of Hodgkin’s disease as a teenager.   

❍ D.  The client’s brother had leukemia as a child.  

 13. Where is the best site for examining for the presence of petechiae in an African American client?   

❍ A.  The abdomen   

❍ B.  The thorax   

❍ C.  The earlobes   

❍ D.  The soles of the feet   

14. The client is being evaluated for possible acute leukemia. Which inquiry by the nurse is most important?   

❍ A.  ―Have you noticed a change in sleeping habits recently?‖   

❍ B.  ―Have you had a respiratory infection in the last 6 months?‖   

❍ C.  ―Have you lost weight recently?‖   

❍ D.  ―Have you noticed changes in your alertness?‖  

15. Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?   

❍ A.  Oral mucous membrane, altered related to chemotherapy   

❍ B.  Risk for injury related to thrombocytopenia   

❍ C.  Fatigue related to the disease process   

❍ D. Interrupted family processes related to life-threatening illness of a family member   

16. A 21-year-old male with Hodgkin’s lymphoma is a senior at the local uni-versity. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client?  

❍ A.  Sexual dysfunction related to radiation therapy   

❍ B.  Anticipatory grieving related to terminal illness   

❍ C.  Tissue integrity related to prolonged bed rest   

❍ D.  Fatigue related to chemotherapy   

17. A client has autoimmune thrombocytopenic purpura. To determine the client’s response to treatment, the nurse would monitor:   

❍ A.  Platelet count   

❍ B.  White blood cell count   

❍ C.  Potassium levels   

❍ D.  Partial prothrombin time (PTT)   

18. The home health nurse is visiting a client with autoimmune thrombocy-topenic purpura (ATP). The client’s platelet count currently is 80,000. It will be most important to teach the client and family about:   

❍ A.  Bleeding precautions   

❍ B.  Prevention of falls   

❍ C.  Oxygen therapy   

❍ D.  Conservation of energy  

 19. The client has surgery for removal of a Prolactinoma. Which of the fol-lowing interventions would be appropriate for this client?   

❍ A. Place the client in Trendelenburg position for postural drainage   

❍ B.  Encourage coughing and deep breathing every 2 hours   

❍ C.  Elevate the head of the bed 30°   

❍ D.  Encourage the Valsalva maneuver for bowel movements 

20. The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is:   

❍ A.  Measure the urinary output 

❍ B.  Check the vital signs   

❍ C.  Encourage increased fluid intake   

❍ D.  Weigh the client   

21. A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?   

❍ A.  Place the client in a sitting position.   

❍ B.  Administer acetaminophen (Tylenol).   

❍ C.  Pinch the soft lower part of the nose.   

❍ D.  Apply ice packs to the forehead.  

 22. A client has had a unilateral adrenalectomy to remove a tumor. The most important measurement in the immediate post-operative period for the nurse to take is to:   

❍ A.  Check the blood pressure   

❍ B.  Monitor the temperature   

❍ C.  Evaluate the urinary output  

❍ D.  Check the specific gravity of the urine  

 23. A client with Addison’s disease has been admitted with a history of nau-sea and vomiting for the past 3 days. The client is receiving IV glucocor-ticoids (Solu-Medrol). Which of the following interventions would the nurse implement?   

❍ A.  Glucometer readings as ordered   

❍ B.  Intake/output measurements   

❍ C.  Evaluate the sodium and potassium levels   

❍ D.  Daily weights   

24. A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurses’ next action be?   

❍ A.  Obtain a crash cart   

❍ B.  Check the calcium level   

❍ C.  Assess the dressing for drainage   

❍ D.  Assess the blood pressure for hypertension  

25. A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in 4 months, and the client is wear-ing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?  

 ❍ A.  Impaired physical mobility related to decreased endurance   

❍ B.  Hypothermia r/t decreased metabolic rate   

❍ C.  Disturbed thought processes r/t interstitial edema   

❍ D.  Decreased cardiac output r/t bradycardia   

26. The client presents to the clinic with a serum cholesterol of 275mg/dL and is placed on rosuvastatin (Crestor). Which instruction should be given to the client taking rosuvastatin (Crestor)?   

❍ A.  Report muscle weakness to the physician.   

❍ B.  Allow six months for the drug to take effect.   

❍ C.  Take the medication with fruit juice.   

❍ D.  Report difficulty sleeping.   

27. The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During administration, the nurse should:   

❍ A.  Utilize an infusion pump   

❍ B.  Check the blood glucose level   

❍ C.  Place the client in Trendelenburg position   

❍ D.  Cover the solution with foil   

28. The 6-month-old client with a ventral septal defect is receiving Digitalis for regulation of his heart rate. Which finding should be reported to the doctor?   

❍ A.  Blood pressure of 126/80   

❍ B.  Blood glucose of 110mg/dL   

❍ C.  Heart rate of 60bpm   

❍ D.  Respiratory rate of 30 per minute  

 29. The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:   

❍ A.  Replenish his supply every 3 months   

❍ B.  Take one every 15 minutes if pain occurs   

❍ C.  Leave the medication in the brown bottle   

❍ D.  Crush the medication and take with water    

30. The client is instructed regarding foods that are low in fat and choles-terol. Which diet selection is lowest in saturated fats?   

❍ A.  Macaroni and cheese   

❍ B.  Shrimp with rice   

❍ C.  Turkey breast   

❍ D.  Spaghetti with meat sauce   

31. The client is admitted with left-sided congestive heart failure. In assess-ing the client for edema, the nurse should check the:   

❍ A.  Feet   

❍ B.  Neck   

❍ C.  Hands   

❍ D.  Sacrum   

32. The nurse is checking the client’s central venous pressure. The nurse should place the zero of the manometer at the:   

❍ A.  Phlebostatic axis   

❍ B.  PMI   

❍ C.  Erb’s point   

❍ D.  Tail of Spence   

33. The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:   

❍ A.  Question the order   

❍ B.  Administer the medications 

❍ C.  Administer separately   

❍ D.  Contact the pharmacy 

  34. The best method of evaluating the amount of peripheral edema is:  

❍ A.  Weighing the client daily   

❍ B.  Measuring the extremity   

❍ C. Measuring the intake and output   

❍ D.  Checking for pitting

35. A client with vaginal cancer is being treated with a radioactive vaginal implant. The client’s husband asks the nurse if he can spend the night with his wife. The nurse should explain that:   

❍ A. Overnight stays by family members is against hospital policy.   

❍ B. There is no need for him to stay because staffing is adequate. 

❍ C.  His wife will rest much better knowing that he is at home. 

❍ D. Visitation is limited to 30 minutes when the implant is in place.  

 36. The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client?   

❍ A.  Roast beef sandwich, potato chips, pickle spear, iced tea   

❍ B.  Split pea soup, mashed potatoes, pudding, milk   

❍ C.  Tomato soup, cheese toast, Jello, coffee   

❍ D.  Hamburger, baked beans, fruit cup, iced tea   

37. The physician has prescribed Novalog insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?   

❍ A. ―I will make sure I eat breakfast within 10 minutes 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.‖   

38. The nurse is teaching basic infant care to a group of first-time parents. The nurse should explain that a sponge bath is recommended for the first 2 weeks of life because:   

❍ A.  New parents need time to learn how to hold the baby.   

❍ B.  The umbilical cord needs time to separate.   

❍ C.  Newborn skin is easily traumatized by washing.   

❍ D. The chance of chilling the baby outweighs the benefits of bathing.

39. A client with leukemia is receiving Trimetrexate. After reviewing the client’s chart, the physician orders Wellcovorin (leucovorin calcium). The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to:   

❍ A. Treat iron-deficiency anemia caused by chemotherapeutic agents   

❍ B.  Create a synergistic effect that shortens treatment time   

❍ C.  Increase the number of circulating neutrophils   

❍ D.  Reverse drug toxicity and prevent tissue damage   

40. A 4-month-old is brought to the well-baby clinic for immunization. In addition to the DPT and polio vaccines, the baby should receive:   

❍ A.  Hib titer   

❍ B.  Mumps vaccine   

❍ C.  Hepatitis B vaccine   

❍ D.  MMR   

41. The physician has prescribed Nexium (esomeprazole) for a client with erosive gastritis. The nurse should administer the medication:   

❍ A.  30 minutes before a meal   

❍ B.  With each meal   

❍ C.  In a single dose at bedtime   

❍ D.  30 minutes after meals  

 42. A client on the psychiatric unit is in an uncontrolled rage and is threaten-ing other clients and staff. What is the most appropriate action for the nurse to take?   

❍ A.  Call security for assistance and prepare to sedate the client.   

❍ B. Tell the client to calm down and ask him if he would like to play cards.   

❍ C. Tell the client that if he continues his behavior he will be pun-ished.   

❍ D.  Leave the client alone until he calms down. 

 43. When the nurse checks the fundus of a client on the first postpartum day, she notes that the fundus is firm, is at the level of the umbilicus, and is displaced to the right. The next action the nurse should take is to:   

❍ A.  Check the client for bladder distention   

❍ B.  Assess the blood pressure for hypotension   

❍ C.  Determine whether an oxytocic drug was given   

❍ D.  Check for the expulsion of small clots   

44. A client is admitted to the hospital with a temperature of 99.8°F, com-plaints of blood-tinged hemoptysis, fatigue, and night sweats. The client’s symptoms are consistent with a diagnosis of:   

❍ A.  Pneumonia   

❍ B.  Reaction to antiviral medication   

❍ C.  Tuberculosis   

❍ D.  Superinfection due to low CD4 count  

 45. The client is seen in the clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan succinate) is prescribed for the client. Which of the following in the client’s history should be reported to the doctor?   

❍ A.  Diabetes   

❍ B.  Prinzmetal’s angina   

❍ C.  Cancer   

❍ D.  Cluster headaches   

46. The client with suspected meningitis is admitted to the unit. The doctor is performing an assessment to determine meningeal irritation and spinal nerve root inflammation. A positive Kernig’s sign is charted if the nurse notes:   

❍ A.  Pain on flexion of the hip and knee   

❍ B.  Nuchal rigidity on flexion of the neck   

❍ C.  Pain when the head is turned to the left side   

❍ D.  Dizziness when changing positions   

47. The client with Alzheimer’s disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting:   

❍ A.  Agnosia   

❍ B.  Apraxia   

❍ C.  Anomia   

❍ D.  Aphasia    

48. The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as:

❍ A.  Chronic fatigue syndrome   

❍ B.  Normal aging   

❍ C.  Sundowning   

❍ D.  Delusions   

49. The client with confusion says to the nurse, ―I haven’t had anything to eat all day long. When are they going to bring breakfast?‖ The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Which response would be best for the nurse to make?   

❍ A.  ―You know you had breakfast 30 minutes ago.‖   

❍ B. ―I am so sorry that they didn’t get you breakfast. I’ll report it to the charge nurse.‖   

❍ C. ―I’ll get you some juice and toast. Would you like something else?‖   

❍ D. ―You will have to wait a while; lunch will be here in a little while.‖   

50. The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer’s disease. Which side effect is most often associated with this drug?   

❍ A.  Urinary incontinence   

❍ B.  Headaches   

❍ C.  Confusion   

❍ D.  Nausea   

51. A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?   

❍ A.  Document the finding   

❍ B.  Report the finding to the doctor   

❍ C.  Prepare the client for a C-section   

❍ D.  Continue primary care as prescribed   

52. A client with a diagnosis of HPV is at risk for which of the following?   

❍ A.  Hodgkin’s lymphoma   

❍ B.  Cervical cancer   

❍ C.  Multiple myeloma   

❍ D.  Ovarian cancer   

 53. During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:   

❍ A.  Syphilis   

❍ B.  Herpes   

❍ C.  Gonorrhea   

❍ D.  Condylomata   

54. A client visiting a family planning clinic is suspected of having an STI. The best diagnostic test for treponema pallidum is:   

❍ A.  Venereal Disease Research Lab (VDRL)   

❍ B.  Rapid plasma reagin (RPR)   

❍ C.  Florescent treponemal antibody (FTA)   

❍ D.  Thayer-Martin culture (TMC)   

55. A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome?   

❍ A.  Elevated blood glucose   

❍ B.  Elevated platelet count   

❍ C.  Elevated creatinine clearance   

❍ D.  Elevated hepatic enzymes   

56. The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?   

❍ A. The nurse places her thumb on the muscle inset in the ante-cubital space and taps the thumb briskly with the reflex ham-mer.   

❍ B. The nurse loosely suspends the client’s arm in an open hand while tapping the back of the client’s elbow.   

❍ C. The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer.   

❍ D. The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist. 

57. A primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor’s order should the nurse question?   

❍ A.  Magnesium sulfate 4gm (25%) IV   

❍ B.  Brethine 10mcg IV   

❍ C.  Stadol 1mg IV push every 4 hours as needed prn for pain   

❍ D.  Ancef 2gm IVPB every 6 hours   

58. A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. The nurse’s assessment of this data is:   

❍ A.  The infant is at low risk for congenital anomalies.   

❍ B.  The infant is at high risk for intrauterine growth retardation.   

❍ C.  The infant is at high risk for respiratory distress syndrome.   

❍ D.  The infant is at high risk for birth trauma.  

59. Which observation in the newborn of a diabetic mother would require immediate nursing intervention?   

❍ A.  Crying   

❍ B.  Wakefulness   

❍ C.  Jitteriness   

❍ D.  Yawning   

60. The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is:  

❍ A.  Decreased urinary output   

❍ B.  Hypersomnolence   

❍ C.  Absence of knee jerk reflex   

❍ D.  Decreased respiratory rate   

61. The client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension, the nurse would:   

❍ A.  Place her in Trendelenburg position   

❍ B.  Decrease the rate of IV infusion   

❍ C.  Administer oxygen per nasal cannula   

❍ D.  Increase the rate of the IV infusion   

62. A client has cancer of the pancreas. The nurse should be most con-cerned about which nursing diagnosis?   

❍ A.  Alteration in nutrition   

❍ B.  Alteration in bowel elimination   

❍ C.  Alteration in skin integrity   

❍ D.  Ineffective individual coping   

63. The nurse is caring for a client with uremic frost. The nurse is aware that uremic frost is often seen in clients with:   

❍ A.  Severe anemia   

❍ B.  Arteriosclcrosis   

❍ C.  Liver failure   

❍ D.  Parathyroid disorder   

64. The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client’s most appropriate priority nurs-ing diagnosis?   

❍ A.  Alteration in cerebral tissue perfusion   

❍ B.  Fluid volume deficit   

❍ C.  Ineffective airway clearance 

❍ D.  Alteration in sensory perception   

65. The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:   

❍ A.  Likes to play football   

❍ B.  Drinks carbonated drinks   

❍ C.  Has two sisters   

❍ D.  Is taking acetaminophen for pain  

 66. The nurse working the organ transplant unit is caring for a client with a white blood cell count of 450. During evening visitation, a visitor brings a basket of fruit. What action should the nurse take?   

❍ A.  Allow the client to keep the fruit   

❍ B.  Place the fruit next to the bed for easy access by the client   

❍ C.  Offer to wash the fruit for the client   

❍ D.  Ask the family members to take the fruit home      

67. The nurse is caring for the client following a laryngectomy when sudden-ly the client becomes nonresponsive and pale, with a BP of 90/40. The initial nurse’s action should be to:   

❍ A.  Place the client in Trendelenburg position   

❍ B.  Increase the infusion of normal saline   

❍ C.  Administer atropine intravenously   

❍ D.  Move the emergency cart to the bedside   

68. The client admitted 2 days earlier with a lung resection accidentally pulls out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes?   

❍ A.  Order a chest x-ray   

❍ B.  Reinsert the tube   

❍ C.  Cover the insertion site with a Vaseline gauze   

❍ D.  Call the doctor   

69. A client being treated with sodium warfarin (Coumadin) has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan?   

❍ A.  Assess for signs of abnormal bleeding   

❍ B.  Anticipate an increase in the Coumadin dosage   

❍ C.  Instruct the client regarding the drug therapy   

❍ D.  Increase the frequency of neurological assessments   

70. Which selection would provide the most calcium for the client who is 4 months pregnant? 

❍ A.  A granola bar   

❍ B.  A bran muffin   

❍ C.  A cup of yogurt   

❍ D.  A glass of fruit juice  

 71. The client with preeclampsia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates the understand-ing of magnesium toxicity?   

❍ A.  The nurse performs a vaginal exam every thirty minutes.   

❍ B.  The nurse places a padded tongue blade at the bedside.   

❍ C.  The nurse inserts a Foley catheter.   

❍ D.  The nurse darkens the room.  

72. The best size cathlon for administration of a blood transfusion to a six year old is:   

❍ A.  18 gauge   

❍ B.  19 gauge   

❍ C.  22 gauge   

❍ D.  20 gauge  

 73. A client is admitted to the unit 2 hours after an explosion causes burns to the face. The nurse would be most concerned with the client develop-ing which of the following?   

❍ A.  Hypovolemia   

❍ B.  Laryngeal edema   

❍ C.  Hypernatremia   

❍ D.  Hyperkalemia   

74. The client has recently been diagnosed with diabetes. Which of the fol-lowing indicates understanding of the management of diabetes?   

❍ A.  The client selects a balanced diet from the menu.   

❍ B.  The client can tell the nurse the normal blood glucose level.   

❍ C.  The client asks for brochures on the subject of diabetes.   

❍ D.  The client demonstrates correct insulin injection technique.   

75. The client is admitted following cast application for a fractured ulna. Which finding should be reported to the doctor? 

❍ A.  Pain at the site   

❍ B.  Warm fingers   

❍ C.  Pulses rapid   

❍ D.  Paresthesia of the fingers   

76. The client with AIDS should be taught to:   

❍ A.  Avoid warm climates.   

❍ B.  Refrain from taking herbals. 

❍ C.  Avoid exercising.   

❍ D.  Report any changes in skin color.   

77. Which action by the healthcare worker indicates a need for further teaching?   

❍ A. The nursing assistant ambulates the elderly client using a gait belt.   

❍ B.  The nurse wears goggles while performing a venopuncture.   

❍ C.  The nurse washes his hands after changing a dressing.   

❍ D.  The nurse wears gloves to monitor the IV infusion rate.   

78. The client is having electroconvulsive therapy for treatment of severe depression. Prior to the ECT the nurse should: 

❍ A.  Apply a tourniquet to the client’s arm.   

❍ B.  Administer an anticonvulsant medication.   

❍ C.  Ask the client if he is allergic to shell fish.   

❍ D.  Apply a blood pressure cuff to the arm.   

79. The 5-year-old is being tested for enterobiasis (pinworms). Which symp-tom is associated with enterobiasis?   

❍ A.  Rectal itching   

❍ B.  Nausea   

❍ C.  Oral ulcerations   

❍ D.  Scalp itching   

80. The nurse is teaching the mother regarding treatment for pedicalosis capitis. Which instruction should be given regarding the medication?   

❍ A. Treatment is not recommended for children less than 10 years of age.   

❍ B.  Bed linens should be washed in hot water.   

❍ C.  Medication therapy will continue for 1 year.   

❍ D.  Intravenous antibiotic therapy will be ordered.   

81. The registered nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?   

❍ A.  The client with HIV   

❍ B.  The client with a radium implant for cervical cancer   

❍ C.  The client with RSV (respiratory synctial virus)   

❍ D.  The client with cytomegalovirus  

  

 82. The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?   

❍ A. The client with methcillin resistant-staphylococcus aureas (MRSA)   

❍ B.  The client with diabetes   

❍ C.  The client with pancreatitis   

❍ D.  The client with Addison’s disease   

83. The doctor accidently cuts the bowel during surgery. As a result of this action, the client develops an infection and suffers brain damage. The doctor can be charged with:   

❍ A.  Negligence   

❍ B.  Tort   

❍ C.  Assault   

❍ D.  Malpractice   

84. Which assignment should not be performed by the nursing assistant?  

❍ A.  Feeding the client   

❍ B.  Bathing the client   

❍ C.  Obtaining a stool   

❍ D.  Administering a fleet enema   

85. The mother calls the clinic to report that her newborn has a rash on his forehead and face. Which action is most appropriate?   

❍ A. Tell the mother to wash the face with soap and apply powder. 

❍ B. Tell her that 30% of newborns have a rash that will go away by one month of life.   

❍ C.  Report the rash to the doctor immediately.   

❍ D. Ask the mother if anyone else in the family has had a rash in the last six months.   

86. Which nurse should not be assigned to care for the client with a radium implant for vaginal cancer?   

❍ A.  The LPN who is 6 months postpartum   

❍ B.  The RN who is pregnant   

❍ C.  The RN who is allergic to iodine

❍ D.  The RN with a 3 year old at home  

 87. Which information should be reported to the state Board of Nursing?   

❍ A. The facility fails to provide literature in both Spanish and English.   

❍ B. The narcotic count has been incorrect on the unit for the past 3 days.   

❍ C. The client fails to receive an itemized account of his bills and services received during his hospital stay.   

❍ D. The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath.   

88. The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should:   

❍ A.  Call the Board of Nursing   

❍ B.  File a formal reprimand   

❍ C.  Terminate the nurse   

❍ D.  Charge the nurse with a tort 

89. The home health nurse is planning for the day’s visits. Which client should be seen first? 

❍ A. The 78-year-old who had a gastrectomy 3 weeks ago and has a PEG tube   

❍ B. The 5-month-old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension   

❍ C. The 50-year-old with MRSA being treated with Vancomycin via a PICC line   

❍ D. The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter   

90. The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster?   

❍ A. A client having auditory hallucinations and the client with ulcerative colitis   

❍ B.  The client who is pregnant and the client with a broken arm   

❍ C. A child who is cyanotic with severe dypsnea and a client with a frontal head injury   

❍ D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain  

91. Before administering eardrops to a toddler, the nurse should recognize that it is essential to consider which of the   following? 

❍ A.  The age of the child.   

❍ B.  The child’s weight.   

❍ C.  The developmental level of the child.   

❍ D.  The IQ of the child.   

92. The nurse is discussing meal planning with the mother of a 2-year-old. Which of the following statements, if made by the mother, would require a need for further instruction?   

❍ A.  ―It is okay to give my child white grape juice for breakfast.‖   

❍ B.  ―My child can have a grilled cheese sandwich for lunch.‖   

❍ C. ―We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch.‖   

❍ D.  ―For a snack, my child can have ice cream.‖   

93. A client with AIDS has a viral load of 200 copies per ml. The nurse should interpret this finding as:   

❍ A.  The client is at risk for opportunistic diseases.   

❍ B.  The client is no longer communicable.   

❍ C. The client’s viral load is extremely low so he is relatively free of circulating virus.   

❍ D.  The client’s T-cell count is extremely low.   

94. The client has an order for sliding scale insulin at 1900 hours and Lantus insulin at the same hour. The nurse should:   

❍ A.  Administer the two medications together.   

❍ B.  Administer the medications in two injections.   

❍ C. Draw up the Lantus insulin and then the regular insulin and administer them together.   

❍ D. Contact the doctor because these medications should not be given to the same client.  

 95. A priority nursing diagnosis for a child being admitted from surgery fol-lowing a tonsillectomy is:   

❍ A.  Altered nutrition   

❍ B.  Impaired communication   ❍ C.  Risk for injury/aspiration   ❍ D.  Altered urinary elimination

96. What would the nurse expect the admitting assessment to reveal in a client with glomerulonephritis?   

❍ A.  Hypertension   

❍ B.  Lassitude   

❍ C.  Fatigue   

❍ D.  Vomiting and diarrhea   

97. Which action is contraindicated in the client with epiglottis?   

❍ A.  Ambulation   

❍ B.  Oral airway assessment using a tongue blade   

❍ C.  Placing a blood pressure cuff on the arm   

❍ D.  Checking the deep tendon reflexes.   

98. A 25-year-old client with a goiter is admitted to the unit. What would the nurse expect the admitting assessment to reveal?   

❍ A.  Slow pulse   

❍ B.  Anorexia   

❍ C.  Bulging eyes   

❍ D.  Weight gain   

99. Which of the following foods, if selected by the mother with a child with celiac, would indicate her understanding of the dietary instructions?   

❍ A.  Whole-wheat toast   

❍ B.  Angel hair pasta   

❍ C.  Reuben on rye   

❍ D.  Rice cereal   

100. The first action that the nurse should take if she finds the client has an O2 saturation of 68% is:   

❍ A.  Elevate the head   

❍ B.  Recheck the O2 saturation in 30 minutes   

❍ C.  Apply oxygen by mask   

❍ D.  Assess the heart rate  

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