Nclex-Rn Essential Questions and Rationales

101 Essential Questions
for the RN-to-Be!

NCLEX RN Review-Including
Priority and Delegation
by
Rhonda Gumbs-Savain
and
Derrice Jordan
2008 Rhonda Gumbs-Savain and Derrice Jordan. All Rights Reserved.

No part of this book may be reproduced, stored in a retrieval system, or transmitted by any means without the written
permission of the author.
First published by AuthorHouse 08/04/08
ISBN: 1-4208-5671-5 (sc)
Library of Congress Control Number: 2005904639
Printed in the United States of America
Bloomington, Indiana
This book is printed on acid-free paper.
Contributors and Consultants
Patricia A. Mahoney, MSN, RN

Nurse Educator Consultants
Carver, MA
Diana J. Mosley, MA, MEd., RN

LaGuardia Community College
Long Island City, NY
Tracy A. Ortelli, MS, RN

Nurse Educator Consultants
New York, NY
Rebecca Rivera
Illustrator and Graphic Designer
Bronx, NY
An inspirational reminder of why Nurses are special

Nursing is a special calling,
Where only the best belong
An evolving journey where we advocate caring for all, neglecting none
And when the challenges of our profession,
Seem like more than we could bear,
We seek solace and comfort from within
and whisper a stay on the job prayer
Today, I was so important in the life of the patient
who needed my care
And the world will be better
and different
because I was there.
Diana J. Mosley, MA, MEd., RN
Adjunct Assistant Professor of Nursing, LaGuardia Community College
Long Island City, NY
vi
Preface
101 Essential Questions for the RN-to-Be was written to be an assistive
guide for nursing students preparing for NCLEX LPN or RN. The book was
designed to inspire new graduates, foreign nurses and repeat test takers. It was
developed as a result of meeting countless nursing students and foreign nurses
who desired a review book that was easy to understand.
The text follows the April 2007 NCLEX RN test plan and the April 2008
NCLEX LPN test plan and is simplied for your convenience. The authors are not
afliated with the National Council of State Boards of Nursing, Inc (NCSBN), who
is the developer of the NCLEX-RN and LPN exam. The most recent information
is provided up to the date of publication. However, the authors, consultants, editors
and publisher are not responsible for any act committed, or omitted in error as
a result of application of the interventions and information provided in this text.
Please contact your local state board of nursing and the National Council of State
Boards of Nursing (NCSBN) for the most current information and or changes to the
NCLEX exam prior to your test date. NCSBN: www.ncsbn.org
The following test plan structure is copyright of the National Council of State
Boards of Nursing, Inc. All Rights Reserved.
About NCLEX
The NCLEX is designed to determine whether you meet the minimal standard to
practice as a nurse.
NCLEX is an integrated exam, which means the subjects are all mixed together.
The test follows the April 2007 NCLEX RN/April 2008 LPN plan. Questions are
drawn from four categories. The following test plan structure is copyright of the
National Council of State Boards of Nursing, Inc. All Rights Reserved. Below is a
list of categories with corresponding percentages for the RN and LPN test plan.
Categories and questions throughout the book with an asterisk (*) emphasize
an RN focus.
I. Safe, Effective Care Environment
A. Management of Care Providing integrated, cost-effective care to
clients by coordinating, supervising and/or collaborating with members of
the multi-disciplinary health care. RN 13-19 % LPN 12-18 %
vii

Advance Directives
Advocacy
Case Management*
Client Rights
Collaboration with
Multidisciplinary Team*
Concepts of Management
Condentiality
Consultation
Continuity of Care
Delegation*
Establishing Priorities
Ethical Practice
Informed Consent
Information technology
Information security
Legal Rights and Responsibilities
Performance improvement (Quality Assurance)
Referrals
Resource Management
Staff education
Supervision*
B. Safety and Infection Control- Protecting clients and health care

personnel from environmental hazards. RN/LPN 8-14 %

Accident Prevention
Disaster Planning/ Internal and external plans*
Emergency Response* Plan
Error Prevention*
Ergonomic principles
Handling Hazardous and Infectious Materials
Home Safety
Injury Prevention
Medical and Surgical Asepsis
Reporting of incident/Event/Irregular Occurrence/Variance
Safe Use of Equipment
viii
Security Plan
Standard/Transmission-Based/Other Precautions
Restraints/Safety Devices
II. Health Promotion and Maintenance - Providing and directing nursing
care of the client and family/signicant others that incorporates the
knowledge of expected growth and development principles, prevention
and/or early detection of health problems, and strategies to achieve optimal
health. RN 6-12% LPN 7-13%

Aging Process
Ante/Intra/Postpartum and Newborn Care
Data collection techniques
Developmental Stages and Transitions
Disease Prevention
Expected Body Image Changes
Family Planning
Family Systems*
Growth and Development
Health and wellness
Health Promotion Programs
Health Screening
High Risk Behaviors

Human sexuality
Immunizations
Lifestyle Choices
Principles of Teaching and Learning*
Self Care
Techniques of Physical Assessment*
III. Psychosocial Integrity Providing and directing nursing care that

promotes and supports the emotional, mental, and social well-being of the
client and family/signicant others experiencing stressful events, as well as
clients with acute or chronic mental illness. RN 6-12% LPN 8-14%

Abuse/Neglect
Behavioral Interventions
Chemical Dependency
Coping Mechanisms
ix

Crisis Intervention
Cultural Diversity
End of Life
Family Dynamics
Grief and Loss
Mental Health Concepts
Psychopathology
Religious and Spiritual Inuences on Health
Sensory/Perceptual Alterations
Situational Role Changes
Stress Management
Substance Related Disorders
Support Systems
Suicide/Violence Precautions
Therapeutic Communications
Therapeutic Environment
Unexpected Body Image Changes
IV. Physiological Integrity

A. Basic Care and Comfort - Providing comfort and assistance in the
performance of activities of daily living. RN 6-12 % LPN 11-17 %

Alternative and Complimentary Therapies*

Assistive Devices
Elimination
Mobility/Immobility
Non-Pharmacological Comfort Interventions
Nutrition and Oral Hydration
Palliative/Comfort Care
Personal Hygiene
Rest and Sleep
B. Pharmacological and Parenteral Therapies - Managing and providing

care related to the administration of medications and parenteral therapies.
RN 13-19 % LPN 9 -15 %
Adverse Effects/Contraindications and Side Effects
Blood and Blood Products*
x

Central Venous Access Devices

Dosage Calculation
Expected Outcomes/Effects
Intravenous Therapy*
Medication Administration
Parenteral uids
Pharmacological Agents/Actions
Pharmacological Interactions
Pharmacological Pain Management*
Total Parenteral Nutrition*
C. Reduction of Risk Potential - Reducing the likelihood that clients will

develop complications or health problems related to existing conditions,
treatments or procedures. RN 13-19 % LPN 10-16 %

Diagnostic Tests
Laboratory Values
Monitoring Conscious Sedation*
Potential for Alterations in Body Systems
Potential for Complications of Diagnostic Tests/Treatments/Procedures
Potential for Complications from Surgical Procedures and Health
Alterations
System Specic Assessments*
Therapeutic Procedures
Vital Signs throughout the life span
D. Physiological Adaptation - Managing and providing care to clients with
acute, chronic or life-threatening physical health conditions. RN/LPN 1117 %

Alterations in Body Systems

Fluid and Electrolyte Imbalances
Hemodynamics
Illness Management*
Infectious Diseases
Medical Emergencies
Pathophysiology
Radiation Therapy
xi
Unexpected Response to Therapies

The test is computer based; you will be required to use a mouse to select the
correct answer.
There is an on screen calculator available to calculate medication dosages.
Once a question is answered you will not be allowed to change it.
NCLEX is a computer adaptive test which means it adjusts based on the

answers you provide to previous questions. For example you will receive
more difcult questions if you answer correctly but easier questions if you do
not. It is very important that you do not guess. It is better to take more time
to answer correctly than to choose answers randomly.
6 hours are allotted for the RN exam to complete a minimum of 75 to a

maximum of 265 questions. The LPN exam allots 5 hours and has 85 to 205
questions. However you should stick to the rule of allowing 1 minute per
question. The analysis level questions may require more than one minute in
order to synthesize all of the information given.
xii
Test Taking Techniques

Critical Thinking is the key to successfully answering
NCLEX questions

Determine what the question is asking.

Identify the topic in question.
Determine relevant facts about the client. The client may not necessarily be the
person with the health problem. It may be a spouse or relative or a health care
team member.
Rephrase the question.
Select the best option after eliminating incorrect choices. Avoid choices that
contain absolute words for example: only, every, always, never, all.
DO NOT read into the question.
Focus on the last line of the question, invariably what the question is asking will
be found there. Look for facts about the client i.e. age, gender, past medical
history, medications, and psychosocial status to provide clues to what the
question is really asking. Look for key words! It is a PAIN. It is imperative to
read every word in the question as well as in the answer choices before making
a selection. Always look for key words in the stem of the question as indicated
below for clues as to the type of response you are looking for. Please study the
following key words and look for these words in the stem of the question before
answering. Rephrase the question and nd out what the question is asking you.
Priority, rst - indicate that you need to determine the most

essential response. Some helpful tools to answer these types of
questions include reviewing the principles of Erikson (if an age
is designated), the nursing theorist OREM (Universal Self Care
Needs), Maslow (Hierarchy of Needs), the Nursing Process
(assessment rst), airway, breathing, circulation (ABCs), time,
expected/ unexpected, safety, disaster and triage
Anticipate, most appropriate, correct, expected, should, include,

instruct indicates that you are looking for a correct or expected
response
Intervene, require follow-up, needs additional teaching, require

further teaching, avoid, notify health care provider indicates that
1
Rhonda Gumbs-Savain and Derrice Jordan
you are looking for an incorrect or unexpected response
Next may imply that you are currently in one phase of the
nursing process and should proceed to the subsequent phase.
Remember Assessment, Diagnoses, Plan, Intervention,
Evaluation (ADPIE).
Questions on delegation should be answered with great care. Never delegate
the assessment portion of the nursing process or tasks that involve complex
procedures. Do not be hasty to choose notify the healthcare provider as an
answer option. Is there some type of action or intervention that you can
perform independently before calling?
Do not answer questions based on your personal experiences. Critical thinking
requires that you think purposefully with outcome directed goals. Your thinking
must be aimed at making judgments based on scientic evidence rather than
tradition or guessing. NCLEX is based on textbook knowledge not individual
varied experiences.
Example: The nurse in a well baby clinic has assessed several children today. It
would be a priority for the nurse to suggest follow up for the child who is
(a) 2 months old with a positive babinski reex
(b) 5 months old and does not hold their own bottle
(c) 10 months old who cries around strangers
(d) 18 months old who needs support while ambulating
The words follow up indicate that you are looking for an incorrect response.
Which of the previous choices are not expected for a child of that age or level of
development? Knowledge of growth and development would help you to select the
most appropriate response. The correct answer is d.
101 Essential Questions for the RN-to-Be!
The nursing process; caring; communication; documentation; teaching and

learning are integrated into all client needs categories. Students can nd specic
client need categories and subcategories in the rationale section of this book. Our
book simulates a live exam by including questions which represent all categories
and subcategories as listed above. Additionally, alternate format questions are
incorporated including:

Multiple choice
Select all that apply (multiple response)
Fill in the blank
Pictures and diagrams (hot spot)
Ordered response
And the Journey Continues

Let wisdom guide you, in life, it is not the length of the journey, but
the quality of steps you take to reach your destination.
Diana J. Mosley-Middleton
Are You Ready To Pass?
1. The nurse is reviewing medical prescriptions for newly admitted clients. It

would be a priority for the nurse to follow up with the physician if a client
with
(a) a potassium level of 4.5mEq/L has Kayexalate (sodium polystyrene)
prescribed
(b) a Dilantin (phenytoin) level of 8 mcg/ml is placed on seizure precautions
(c) sensitivity to Aspirin (acetylsalicylic acid) is prescribed Tylenol
(acetaminophen)
(d) sensitivity to Penicillin is prescribed Zithromax (azithromycin)
2. The nurse should intervene if the nurse notes a staff member
(a) obtaining a clients consent prior to their operative procedure after
receiving Ativan (lorazepam)
(b) placing a client on the affected side following surgical repair of a retinal
detachment
(c) handling a wet cast with the palms of the hands
(d) using a broad base of support while transferring a client
3. The community health nurse is caring for the following clients. It would be a
priority for the nurse to initiate a multidisciplinary conference for the client
who is
(a) 12 years old with Autism who is starting a new school and recently had a
URI (upper respiratory tract infection)
(b) 16 years old, has type 1 Diabetes Mellitus, is unemployed and had a recent
Hemoglobin A1c of 13%
(c) 52 years old, with Myasthenia Gravis, recently prescribed Mestinon
(pyridostigmine) and employed as a mail carrier
(d) 70 years old, has schizophrenia, lives alone and reports hearing non
threatening voices.
4. The nurse from the postpartum unit has been temporarily assigned to the
medical surgical unit. It would be most appropriate to assign this nurse to
the client who*
(a) has returned from right total hip replacement surgery four hours ago
(b) is being observed for increased intracranial pressure
(c) had surgery two hours ago to remove the appendix
(d) is two weeks post partum being maintained on a mechanical ventilator for
respiratory failure
5. The nurse in a well baby clinic has assessed several children today. It would
be a priority for the nurse to suggest follow up for the child who is
(a) 2 months old with a positive babinski reex
(b) 5 months old and does not hold their own bottle
(c) 10 months old who cries around strangers
(d) 18 months old who needs support while ambulating
6. The nurse is caring for a mechanically ventilated client who was declared
brain dead. An Advance Directive is not documented on the medical record.
It would be most appropriate to obtain consent for organ donation from the
(a) clients primary care provider
(b) clients nurse manager
(c) closest living family member
(d) hospitals ethics committee
7. The nurse has received report on four clients. The nurse should rst assess
the client who has*
(a) Chronic Obstructive Pulmonary Disease (COPD) with a pulse oximetry
reading of 90%
(b) Parkinsons Disease and is demanding to leave the hospital against medical
advice (AMA)
(c) been admitted with suspected Guillian-Barre Syndrome and has begun
plasmapheresis therapy
(d) Congestive Heart Failure (CHF) whose pitting edema has increased to 2(+)
8. It would be appropriate to assign which of these tasks to the CNA?

(a) Feeding a client who is experiencing dysphagia
(b) One-on-one client observation for safety
(c) Removal of an indwelling catheter
(d) Performing a simple dressing change
9. The nurse should intervene if a staff member is observed
(a) discussing a clients diagnosis with visiting family members
(b) collaborating with another nurse to review a prescription for blood
transfusion
(c) interrupting other staff members discussing a client in the cafeteria
(d) reviewing a clients lab values with the nutritionist
10. The nurse is preparing a staff presentation on legal and ethical issues in
nursing. The nurse would be correct to include which of the following
examples?
(a) Putting a client in a geriatric chair with the lap tray in front of the client
in the day room to watch television is false imprisonment
(b) Telling a client that you will put in a feeding tube if the client does not
eat is an example of battery
(c) Telling a client with bipolar disorder who is suicidal that they have a right
to refuse to take their medications is an example of malpractice
(d) Placing hands on a client who says do not touch me is an example of
assault
11. The nurse from the pediatric unit has been temporarily assigned to the
Emergency Department. It would be most appropriate to assign that nurse
to the client who*
(a) reports epigastric pain that feels like indigestion
(b) has back pain and a pulsating abdominal mass
(c) is HIV+ reporting vomiting and diarrhea
(d) presents with lower abdominal pain and is six weeks pregnant
12. Four clients recently returned to the unit following invasive diagnostic
testing. The nurse should immediately intervene if one of the clients
(a) reports blood tinged sputum following a bronchoscopy
(b) has decreased abdominal girth following paracentesis
(c) reports a headache following a lumbar puncture
(d) is observed exing and extending the legs two hours after cardiac
catheterization
13. The nurse is made aware of the following situations. The nurse should rst
check the client who
(a) had a transurethral prostatectomy (TURP) and is reporting urinary
dribbling two hours after the indwelling catheter is removed
(b) has cervical traction and is moving the legs by exing and extending the
feet
(c) has Alzheimers disease (stage 1) and was returned to the room after being
found wandering in the hallway
(d) has a history of partial seizures and is sitting in the bed picking at the
clothing and smacking the lips
14. The nurse in a community health clinic is talking with the parent of a child
with Celiac Disease. Which of the following statements would require
follow-up by the nurse for additional teaching?
(a) This weekend we are going to a seafood restaurant.
(b) I can feed my child oatmeal and eggs for breakfast.
(c) My child loves to eat rice and chicken for dinner.
(d) Last night we ate sh with corn for dinner.
15. The charge nurse is observing a Licensed Practical Nurse (LPN) performing
care for assigned clients. Follow up will be required if the LPN*:
(a) assesses a clients apical pulse before administering Digoxin (lanoxin)
(b) elevates the clients stump on a pillow eight hours after amputation
(c) dons a clean glove on the dominant hand before tracheal suctioning
(d) positions a client on the operative side following a pneumonectomy
16. The nurse at a health promotion fair has taught a group of parents about car
seat and seat belt safety. Which of the following statements, if made by the
parent, would indicate a correct understanding of the information given?
(a) I will place my newborn infant in a rear facing car seat in the middle of
the rear seat.
(b) I will wear a lap seat belt high on my belly since I am 8 months
pregnant.
(c) I can use a front-facing car seat once my baby weighs 15 pounds.
(d) I can allow my six-year-old to use a seat belt in the front passenger
seat.
17. The nurse is caring for a client being treated for Vancomycin Resistant
Enterococcus (VRE). The nurse should place the client on
(a) contact precautions
(b) droplet precautions
(c) protective precautions
(d) airborne precautions
18. The nurse is caring for a client with a Vancomycin Resistant Enterococcus
(VRE) wound infection. Which of the following actions would be appropriate
for the nurse to take?
(a) Wear a particulate respirator mask when providing wound care
(b) Instruct visitors not to bring owers into the clients room
(c) Place the client in a private room with negative air pressure
(d) Wear a disposable gown when changing the clients dressing
19. The nurse should initiate protective precautions for a client who has a
(a) Red Blood Cell Count (RBC) of 3,900/mm3
(b) Platelet count of 400,000/L
(c) Hemoglobin (Hgb) 9.0 g/dl
(d) White Blood Cell Count (WBC) 2,500/mm3
20. The nurse has provided health promotion teaching for a group of clients who
were recently diagnosed with the Human immunodeciency virus (HIV). Which
statement, if made by one of the clients, would require further teaching?
(a) I am glad that I can still clean my parakeets cage.
(b) I will not go to the parade this weekend.
(c) I will increase protein in my diet.
(d) I will miss not being able to work in my garden.
21. The nurse in the emergency department is caring for clients admitted
following a rescue from a burning bus. The nurse should rst see the client
who
(a) has the tibia bone protruding through the skin and is in severe pain
(b) has third degree burns of the left foot and is crying
(c) is unconscious, pulseless, and has dilated pupils
(d) has soot on the face and the nares and is coughing
22. A nurse is observing a newly-hired nurse provide care for assigned clients. The
nurse should follow up if the newly-hired nurse is observed
(a) wearing gloves when taking the blood pressure of a client with
disseminated varicella zoster
(b) cleansing the wound from the outer surface to the inner surface for a
client whose wound is infected with a multi-drug resistant organism
(c) washing the hands with the ngertips pointed downward before providing
care for a client on protective precautions
(d) removing the gloves before removing the gown when leaving a room of a
client who is on contact precautions
23. The nurse is caring for a client who has been diagnosed with rheumatoid
arthritis. The nurse should anticipate that the client will initially be
prescribed
(a) Disease-modifying rheumatic agents (DMARDs)
(b) Nonselective anti-inammatory drugs (NSAIDs)
(c) Long-term corticosteroids
(d) Biologic Response Modiers
24. The nurse is assessing a 2-month-old-infant at a well baby clinic. The nurse
should anticipate the infant should
(a) roll from prone to back
(b) have no head lag
(c) smile socially
(d) have no tonic neck reex
25. The nurse is teaching a class on infant nutrition. The nurse should instruct
parents to introduce
(a) fruit juices at 3 months
(b) honey sweetened water at 6 months
(c) pureed chicken at 7 months
(d) whole milk at 9 months
26. The nurse is caring for a 7-year-old who has thrombocytopenia and is on
protective precautions. Which of the following would be an appropriate toy
for the nurse to provide to the client?
(a) Finger paints and paper
(b) A rubber ball and bat
(c) A board game
(d) A stuffed toy
27. The nurse on a pediatric unit has been informed that the following clients are
being admitted. The nurse should rst plan to assess the client who is*
(a) 2 years old, has a temperature of 100.8 F and a blood pressure of 68/44
(b) 4 years old with a history of asthma and has a peak expiratory ow rate
(PERF) of 81%
(c) 5 years old, has a fracture of the tibia and is reporting pain rated 7 on a
pain scale of 0 (no pain) to 10 (severe pain)
(d) 7 years old with ulcerative colitis and has had 15 blood tinged stools today
10
28. The nurse is providing discharge instructions to the parents of an infant who
has a cleft lip. The nurse should instruct the parents to
(a) place the infant in a prone position after each feeding
(b) encourage the parents to provide the infant rest periods during feedings
(c) regularly offer the infant a pacier to enhance the sucking reex
(d) elevate the childs head forty ve degrees during feeding
29. The nurse is assessing a 3-year-old during a well-child visit. During the visit
the boy says to his mother, Mommy, I love you. Im going to marry you. The
nurse should
(a) suggest to the mother not to encourage these types of statements
(b) explain to the child that he will not be able to marry his mother even
though he loves her
(c) tell the mother that this statement is appropriate for his stage of
development
(d) recommend that the mother provide more opportunities for her son to
play with other 3-year-old boys
30. The nurse is assessing a child with coarctation of the aorta. Which of the
following would be an expected nding?
(a) diminished blood pressure in the upper extremities
(b) excessive weight gain
(c) high pitched murmur
(d) absence of femoral pulses
31. The nurse is caring for a child with an acyanotic heart defect. Which of the
following would be an expected nding. Select all that apply.
(a) ______ poor suck reex
(b) ______ tachycardia
(c) ______ increased respiratory rate
(d) ______ bradycardia
(e) ______ fainting spells
(f) ______ delayed growth and development
11
32. The nurse is teaching a new mother about immunizations. Which of the
following should the nurse include in the teaching?
(a) Your baby should wait six months to receive any immunizations since the
baby was born preterm.
(b) Your baby will receive the rst hepatitis B vaccine after one year of age.
(c) Acellular Pertussis vaccine has less side effects than whole-cell pertussis
vaccine.
(d) The Haemophilus Inuenza Type b (HIB) is given annually to protect
against the u.
33. The mother of an infant tells the nurse that the baby has not been tolerating
feedings lately and she noticed an olive-shaped mass in the infants abdomen.
The nurse recognizes that this could be an expected nding if the infant has
(a) intussusception
(b) Hirschsprungs disease
(c) umbilical hernia
(d) pyloric stenosis
34. The nurse is teaching a group of parents about the expected growth and
development of three-year-old children. The nurse should include that a
three-year-old should
(a) discriminate between fantasy and reality
(b) ride a tricycle independently
(c) have a vocabulary of 7,000 words
(d) play in a group of two or three with one being the leader
12
35. The nurse and the nursing assistant are caring for a group of clients. Which
of the following client care activities should the nurse assign to the nursing
assistant? Select all that apply.
(a) _____ reinforcing the dressing of a client who has a decubitus ulcer
(b) _____monitoring the vital signs of a client who had a myocardial infarction
12 hours ago and is being transferred from the coronary care unit
(c) ______administering a prescribed Fleets enema to a client who will
undergo a colonoscopy in two hours
(d) _____ placing a client who had an above the knee amputation 24 hours
ago in a prone position
(e) _____ assisting a client who had a colon resection 36 hours ago to
ambulate
(f) _____ showing a client who had a vaginal hysterectomy 36 hours ago how
to perform perineal care
36. The nurse is caring for a client with Acquired immunodeciency syndrome
(AIDS) who was started on Zidovidine (AZT). It would be important for the
nurse to assess
(a) blood ammonia serum
(b) serum potassium
(c) complete blood count (CBC)
(d) serum uric acid
37. The nurse is performing an abdominal assessment. Indicate the correct
sequence the nurse should use to perform this assessment.
(a) percussion
(b) palpation
(c) auscultation
(d) inspection
Answer______________
13
38. The nurse has become aware of the following client situations. The nurse
should rst assess the client who*
(a) had received a unit of packed red blood cells four hours ago and is
requesting a bedpan
(b) had an abdominal hysterectomy yesterday and is reporting calf pain
(c) has history of multiple sclerosis and is reporting diplopia
(d) had a tonsillectomy three hours ago and is reporting a sore throat
39. The nurse is caring for a client who has been prescribed 1,000 ml of Ringers
Lactate to infuse over 8 hours. The available intravenous set delivers 10
drops per milliliter. How many drops per minute should the nurse set the
intravenous controller to administer?
Answer ______________
40. The primary health care provider has prescribed an oral solution of Potassium
Chloride (KCL) 20 mEq PO, QD. The drug available is Potassium Chloride 10
mEq/15ml. How many ml should the nurse administer?
Answer______________
41. The primary health care provider has prescribed Heparin 5000 units SC. The
drug available is heparin sodium 7500units/ml. Choose all of the correct
answers for nursing considerations for the administration of heparin sodium.
(a) ______ administer the heparin in the abdomen
(b) ______ administer 0.5ml of heparin sodium
(c) ______ aspirate after inserting the needle
(d) ______ use a 1 inch 21 gauge needle
(e) ______ refrain from massaging the site after administer heparin
(f) ______ remember that protamine sulfate is the antidote for heparin
14
42. The nurse has attended a staff development conference on cultural

considerations for clients receiving hospice care. Which of the following
statements if made by the nurse would require follow-up?
(a) The family of a client of the Buddhist faith may ask for a priest to be
present at the time of death
(b) The family of a client of the Jewish faith may request to have mirrors
covered after the death of the client
(c) The family of a client of the Muslim faith may request that the body of the
client be turned to face the East at the time of the clients death
(d) The family of a client of the Hindu faith may request that the client body
be bathed after the clients death
43. The nurse is caring for a client with bipolar disorder who has Lithium
(Lithotabs) prescribed. The nurse should suggest that the client have which
of the following snacks?
(a) A fresh fruit cup
(b) Coffee and oatmeal cookies
(c) Tuna sh salad on saltine crackers
(d) Raw vegetables
44. The nurse has provided discharge instructions for a client who has been
prescribed Digoxin (Lanoxin). It would require follow up by the nurse if the
client says
(a) I will consult my primary health care provider before taking medications
that contain aspirin.
(b) I will not take any antacids within two hours of taking the digoxin.
(c) I will avoid fruits such as avocados, grapefruit and cantaloupe.
(d) I will remember that any visual disturbance can be a sign of digitalis
toxicity.
15
45. The nurse is caring for a client who has bumetanide (Bumex) prescribed. The
nurse should suggest that the client include which of the following foods in
the diet?
(a) Apricots
(b) Organ meats
(c) Sardines
(d) Apples
46. The nurse is providing teaching for a client with ulcerative colitis. Select all
of the following that the nurse should include in the teaching
(a) ______ steatorrhea commonly occurs or excessive secretion of fecal lipids
is common
(b) ______ ulcerative colitis occurs most frequently in Jewish males 30-50
years of age
(c) ______ a diet high in residue and low in complex carbohydrates is helpful
in controlling symptoms
(d) ______ Corticosteroids may be prescribed during an exacerbation
(e) ______ metronidazole (Flagyl) and ciprooxacin (Cipro) are antibiotics
commonly used during acute exacerbations
(f) ______ eating small frequent meals and lying down after eating promotes
absorption of nutrients
47. The nurse is precepting a newly-hired nurse who is caring for a client
receiving a prescribed continuous nasogastric feeding. The nurse should
intervene immediately if the newly-hired nurse
(a) instills 30cc of normal saline into the feeding tube while auscultating over
the stomach for bowel sounds
(b) checks the pH of the 60ml gastric aspirate removed from the feeding tube
(c) maintains the client with the head of the bed elevated at 45 degrees
(d) hangs four hours worth of prescribed feeding formula in an open delivery
system
16
48. The nurse is observing a staff member caring for clients. It would require
immediate intervention if the nurse observes the staff member
(a) placing a client who had an above-the-knee amputation (AKA) 24 hours
ago in a prone position
(b) keeping the head of the bed elevated for the client who had an
supratentorial craniotomy 12 hours ago
(c) giving orange juice to a client who has a clear liquid diet prescribed
(d) removing all liquids from the tray before giving the tray to a client who
has dumping syndrome
49. The primary health care provider has prescribed ampicillin (Omnipen) 0.5 GM
PO Q6H to a 15 month old toddler who weighs 22 pounds. The drug available
is ampicillin suspension 250 mg/5 ml. The recommended dosage is 50 mg/kg/
day every 6 to 8 hours. The nurse should
(a) call the primary health care provider to report that the prescription
exceeds the recommended dosage
(b) determine if the toddler has previously had a penicillin or a cephalosporin
prescribed
(c) give the toddler the ampicillin mixed with applesauce
(d) wait until the result of the throat culture obtained one hour ago is
reported
50. The nurse is instructing a class for parents of children diagnosed with sickle
cell anemia. The nurse should instruct the parents to have the children avoid
(a) exposure to hot water
(b) other children with infections
(c) medications containing aspirin
(d) non - contact sports
51. The nurse is assessing a 5-month-old infant. The nurse should expect the
infant to
(a) roll from abdomen to back
(b) sit without support
(c) say mama and dada
(d) prefer use of one hand over the other
17
52. The home health care nurse is assigned to see four clients who all live within
three miles of each other. The nurse should rst see the client who has
(a) gastroesophageal reux disease (GERD) and is reporting a burning
abdominal pain that is relieved by walking
(b) cancer of the esophagus who has given away a favorite shirt since the last
visit
(c) regional enteritis (Crohns disease) who has an elevated temperature and
is vomiting
(d) a gastrostomy tube who will begin self-feeding for the rst time
53. A student nurse is administering magnesium hydroxide/aluminum hydrate
(Maalox) prescribed as an antacid to a client. The nursing instructor should
intervene if the student plans to administer the antacid
(a) two hours after the client has eaten a meal
(b) at the same time as a prescribed iron preparation
(c) after briskly shaking the bottle of Maalox
(d) when assessing the client for the presence of gastric pain
54. The nurse has attended a staff development conference on vitamins and
minerals. Which of the following statements if made by the nurse would
require follow-up?
(a) Vitamin B12 (cobalamin) supplement may be needed if a client has a
gastrectomy.
(b) Vitamin D (calciferol) is necessary for proper utilization of calcium and
phosphorous.
(c) Vitamin A can be found in squash, pumpkin, and carrots.
(d) Vitamin B6 (pyridoxine) supplements are given to help prevent macular
degeneration.
18
55. A nurse is caring for a two-month-old infant being evaluated for congenital
hypothyroidism. The nurse should recognize which of the following ndings
as being consistent with congenital hypothyroidism?
(a) The infant sleeps for 6 hours at a time
(b) The infant has a high-pitched cry
(c) The infant has been having frequent loose stools
(d) The infant has 3 + reexes
56. The nurse in the emergency department is assessing a toddler who has
swallowed some bleach. The toddler is crying. It would be a priority for the
nurse to follow up if the parent says
(a) I brought the container of bleach with me.
(b) I could not get my toddler to vomit.
(c) I gave my toddler a tablespoonful of ipecac syrup.
(d) I attempted to perform CPR to prevent my toddler from becoming
unresponsive.
57. The nurse is caring for a client who is ventilator dependent. The nurse is
aware that the high pressure alarm can be sounded for various reasons.
Select all reasons that could apply.
(a) _____ increased bronchial secretions
(b) _____ the presence of an air leak
(c) _____ the presence of a kink in the tubing
(d) _____ the client stops breathing spontaneously
(e) _____ acute bronchospasm
(f) _____ the client is biting the tube
(g) _____ the ventilator tubing is disconnected
19
58. The nurse is caring for a client who has a new colostomy. The colostomy
stoma is red, moist and slightly raised. The nurse should
(a) determine if the client is allergic to the skin barrier
(b) apply petroleum jelly gauze around the stoma
(c) document the condition of the stoma
(d) assess the clients temperature
59. The nurse has attended a staff development conference on medical
treatments for various neurological disorders. Which of the following
statements if made by the nurse would require follow-up?
(a) Clients with Guillain-Barre syndrome (GBS) often have plasmapheresis
prescribed.
(b) Myasthemia Gravis can be treated with short-acting anticholinesterase
drugs.
(c) Parkinsons disease may have catechol O-methyltransferase (COMT)
inhibitors prescribed along with levodopoa-carbidopa (Sinemet).
(d) Clients with Multiple Sclerosis often receive Intravenous immunoglobulin
G (IV IgG).
60. The nurse has attended a staff development conference on Menieres Disease.
Which of the following statements, if made by the nurse would require
follow-up?
(a) Menieres Disease symptoms result from excess endolymphatic uid in
the inner ear.
(b) Clients with Menieres Disease are encouraged to have a low salt diet.
(c) Assistive listening devices are required for clients with Menieres
Disease.
(d) Stress is suspected to have a role in Menieres Disease.
61. The nurse is admitting a client to the emergency department who is reporting
progressive visual impairment and loss of peripheral vision. The nurse should
recognize that these symptoms are consistent with the medical diagnosis of
(a) macular degeneration
(b) closed angle glaucoma
(c) senile cataract
(d) retinal detachment
20
62. The nurse is caring for a client who has left ventricular failure. Which of the
following should the nurse recognize as being consistent with this diagnosis?
(a) 3+ pedal edema
(b) jugular vein distention
(c) oxygen saturation of 96%
(d) wheezing during expiration
63. The nurse has attended a staff development conference on preparing clients
for neurological diagnostic tests. Which of the following statements, if made
by the nurse would require follow-up?
(a) The electromyogram (EMG) is performed by introducing small needle
electrodes into muscles.
(b) After having a Positron Emission Tomography (PET) of the head the client
can resume normal activities.
(c) The electroencephalogram (EEG) will require the client to be NPO for 12
hours before the test.
(d) After the lumbar puncture (LP) the client will need to lie at for about 3
hours.
64. The nurse has become aware of the following client situations. It would be a
priority for the nurse to intervene if a client
(a) who had a cervical radium implant inserted sixteen hours ago is placed on
bed rest
(b) who had transsphenoidal hypophysectomy twelve hours ago is drinking
uids through a straw
(c) who has received prescribed Lithium for the past three days is observed
eating a pickle brought in by a family member
(d) who had retinal detachment repaired using a gas bubble four hours ago is
lying on the operative side postoperatively
65. The nurse is caring for a client who has oxalate kidney stones. The nurse
should teach the client to avoid
(a) Spinach and rhubarb
(b) Mushrooms and rice
(c) Shell sh and aged cheese
(d) Organ meats and wine
21
66. A client with end stage renal disease (ESRD) is scheduled for hemodialysis in
one hour. The nurse should notify the primary health care provider that
the client has a
(a) BUN of 60 mg/dl
(b) Creatinine 3.5 mg/dl
(c) Sodium 145 mEq/L
(d) Potassium 6.8 mEq/L
67. The nurse is caring for a 49 year old female client who reports having
frequent vaginal yeast infections. The client is 35% over her ideal body
weight. The client has had several diagnostic blood tests prescribed. It would
be a priority for the nurse to review the results for an elevated
(a) fasting blood glucose
(b) white blood count
(c) hemoglobin
(d) blood urea nitrogen
68. The nurse at a health clinic is screening male clients for testicular cancer. It
would be a priority for the nurse to teach testicular self examination to
(a) a 17-year-old college football player
(b) a 39-year-old who smokes a pack of cigarettes day
(c) a 55-year-old with benign prostatic hypertrophy
(d) a 69-year-old with a family history of testicular cancer
69. The nurse is caring for a 72-year-old client who was recently diagnosed with
metastatic breast cancer. The client is expressing feelings of depression and
is asking the nurse, Why me? According to Erikson, which developmental
stage is the client experiencing?
(a) Industry vs. inferiority
(b) Ego integrity vs. despair
(c) Generativity vs. stagnation
(d) Intimacy vs. isolation
22
70. The nurse is caring for several clients who have been prescribed diuretics.
The nurse should teach about increasing the consumption of citrus fruits and
bananas to the client who has been prescribed
(a) amiloride (Midamor )
(b) spironolactone (Aldactone)
(c) torsemide (Demadex)
(d) triamterene (Dyrenium )
71. The nurse in a health clinic is reviewing prescribed medications with several
clients. It would be a priority for the nurse to follow up with the client who
states
(a) I am taking losartan (Cozaar) to lower my blood pressure.
(b) I crush my verapamil (Calan SR) to make it easier to swallow.
(c) I try to avoid sudden position changes since I am taking hydralazine
(Apresoline).
(d) I will not use any salt substitutes since I am taking captopril (Capoten).
72. The nurse is developing a plan of care for a client diagnosed with
bromyalgia. Which nursing diagnosis should the nurse include?
(a) Sleep pattern disturbance
(b) Risk for infection
(c) Fluid volume decit
(d) Urge urinary incontinence
73. The nurse has attended a staff development conference on sexually
transmitted diseases. Which of the following statements, if made by the
nurse would require follow-up?
(a) During the primary stage of syphilis a lesion occurs at the site of infection
called a chancre.
(b) A client with HIV who has a reading of 5 or more on the mantoux test is
considered to have a positive nding for pulmonary tuberculosis.
(c) Gonorrhea is often asymptomatic in women but causes urinary frequency
and dysuria in males.
(d) Chlamydial infections are strongly linked with cervical cancer in women.
23
74. The infection control nurse is making rounds on a Medical Surgical unit. The
infection control nurse should immediately intervene if a nurse is observed
(a) wearing a disposable surgical face mask when entering the room of a
client with active pulmonary tuberculosis
(b) keeping the door to the room closed of a client with disseminate varicella
zoster
(c) leaving a dedicated stethoscope in the room of a client with respiratory
syncytial virus
(d) wearing a gown, gloves, and mask while taking the blood pressure of a
client with Ebola Virus
75. The nurse in a community health setting is assessing the following clients. It
would be a priority for the nurse to utilize a multidisciplinary approach for
the client who is*
(a) 12 years old, with chicken pox and cannot attend school
(b) 21 years old, pregnant, unemployed and has active pulmonary tuberculosis
(c) 32 years old, a grade school teacher and is recovering from a sickle cell
crisis
(d) 74 years old, with mild Alzheimers disease and is in an assisted living
residence
76. The nurse working in the labor and delivery room has become aware of the
following client situations. The nurse should rst assess the client who is
(a) in the rst phase of labor and the fetal heart rate ranges from 128 to 140
between contractions
(b) in the rst phase of labor and the fetal heart rate is consistently beating
at 132 beats per minute
(c) in the third phase of labor and the fetal heart rate has decelerated to its
lowest point at the acme of the contraction
(d) in the third phase of labor and the contractions are lasting 60-70 seconds
24
77. The nurse is caring for postpartum clients who had vaginal deliveries within
the last eight hours. The nurse should rst assess the client who
(a) has a pulse rate of 66 beats per minute
(b) has saturated one perineal pad in two hours
(c) reports swelling in her right calf
(d) asks if her baby can sleep in the nursery tonight
priority for the nurse to follow-up if a client who
(a) had a total knee replacement 24 hours ago is using continuous passive
motion (CPM) exerciser while in a supine position
(b) is scheduled for a myelogram in 4 hours and states I can not drink any
liquids until after the procedure is nished.
(c) had a total knee replacement 24 hours ago and is sitting in a fowlers
position to eat a meal
(d) had a pin inserted 4 hours ago for a fractured femur has a small amount of
bright red bleeding at the pin site
79. The nurse is teaching a client about crutch walking. Which of the following
statements if made by the client indicates a need for further teaching?
(a) My elbows should be exed 20 - 30 degrees, while walking.
(b) When I climb stairs I advance my affected leg rst, with my crutches.
(c) I do not apply pressure under my arm when I use my crutches.
(d) When I am going to sit in a chair I put both crutches in the hand on my
unaffected side.
80. The nurse on an orthopedic unit has become aware of the following client
situations. It would be a priority for the nurse to follow-up if a client who
(a) had a total hip replacement 8 hours ago has had 100 ml of bloody drainage
in the closed wound suction device
(b) has an external xation device after a repair of a fractured femur is
requesting pain medication
(c) had an open reduction and internal xation (ORIF) of a fractured femur 12
hours ago has developed a small rash on the chest and neck
(d) had a total hip replacement three hours ago has a temperature of 37.8 C
(100.2 F)
25
81. The nurse is caring for a client with a soft tissue injury. The client reports
using a herbal remedy for 3 weeks prior to seeking health care but can not
remember what was taken. The nurse should recognize that which of the
following herbal remedies can be utilized effectively for soft tissue injuries?
(a) Saint Johns Wort
(b) Kava Kava
(c) DongQuai
(d) Aloe Vera
82. A client with left-sided weakness following a cerebral vascular accident (CVA)
is learning to ambulate with a cane. The nurse should teach the client to
(a) hold the cane on the left side and move the cane with the right leg
(b) hold the cane on the right side and move the cane with the left leg
(c) hold the cane on the left side and move the cane with the left leg
(d) hold the cane on the right side and move the cane with the right leg
priority for the nurse to intervene if a client
(a) scheduled for an EEG is washing the hair
(b) is being transported to have a magnetic resonance image (MRI) test and
is attached to a pulse oximeter
(c) is being taught to hold the breath at intervals during a computerized
tomography (CT Scan)
(d) on protective precautions is eating soup brought in by a visitor
84. The nurse is reviewing laboratory data of the following clients. It would be a
priority for the nurse to follow-up with the primary health care provider if a
client with
(a) coronary artery disease has a low density lipoprotein (LDL) level of
129mg/dl
(b) primary hypertension has a sodium level of 144mEq/L
(c) rhinosinusitis has a white blood count (WBC) of 11,500/ul
(d) diabetes mellitus type 1 has a glycosylated hemoglobin (HbA1c) level
of 12%
26
85. The nurse working on a maternity unit has become aware of the following
client situations. It would be a priority for the nurse to intervene if a client
states
(a) I will not take my terbutaline (Brethine) if my pulse is greater than 110
beats per minute.
(b) It is normal for my 10 hour old baby to have blue feet and hands.
(c) I cannot breast feed because my nipples are cracked and sore.
(d) I have changed my perineal pad every two hours since I delivered my
baby 12 hours ago.
86. The nurse observes an adult collapse on the street. Indicate the correct
sequence for the nurse to follow.
(a) phone emergency medical system at 911
(b) verify unresponsiveness
(c) check for breathing
(d) establish an airway using a head-tilt/chin-lift
Answer ______________
87 A nurse is admitting a client with suspected pulmonary tuberculosis (TB).
Which of the following actions should the nurse take?
(a) wear a gown when taking the clients health history
(b) place the client on droplet precautions
(c) keep the door to the clients room closed
(d) use disposable gloves when taking the clients blood pressure
88. The charge nurse of a medical-surgical unit notices a nurse walking with
an unsteady gait, slurred speech and a faint smell of alcohol on the breath
immediately following a lunch break. The charge nurses priority action
would be to*
(a) notify the nursing supervisor
(b) asking the nurse about recent alcohol consumption
(c) complete an incident report
(d) relieve the nurse of assigned clients
27
89. The staff members of an out patient clinic have successfully assisted the
clients to safety during a re in the waiting area. Which action should the
nurse perform next?
(a) Close all open doors
(b) Call for additional help
(c) Attempt to extinguish the re
(d) Assess the clients vital signs
90. While performing an assessment of a 3-year-old client, the nurse notices
bruises in various stages of healing on the concealed surfaces of the body.
Which action should the nurse take next?
(a) document the locations of the bruises in the medical record
(b) notify the primary health care provider
(c) contact the local reporting agency for suspected child abuse
(d) ask the parent to explain the injuries
91. The nurse in the emergency department is admitting a client who is
hallucinating and reports insects crawling on the skin. The clients pulse rate
is 124 and the respiratory rate is 10. The nurse notes muscle twitching of
the lower extremities. It would be a priority for the nurse to determine if
the client has
(a) a history of attention decit disorder
(b) recently ingested cocaine
(c) taken disulram (Antabuse) within the past 24 hours
(d) an allergy to anticholinergics
92. The nurse is developing a nursing care plan for a client who is in the manic
phase of bipolar disorder. Which intervention should the nurse include in the
plan of care?
(a) Provide the client with nger foods
(b) Engage the client in competitive games
(c) Encourage the client to avoid foods that contain tyramine
(d) Place the client on direct suicide observation
28
93. The primary health care provider has prescribed amitriptyline (Elavil) 150 mg
P.O. daily for a client diagnosed with major depression. Choose all of the
correct answers for nursing considerations for the administration of Elavil.
(a) ______ administer this medication with meals
(b) ______ teach the client that the appetite will be diminished
(c) ______ administer this medication in the morning
(d) ______ monitor the client for hypertension
(e) ______ Instruct the client that this medication may cause the
development of a dry mouth
(f) ______ inform the client that this medication may cause photosensitivity
94. A 45 year old client who was recently diagnosed with terminal cancer says
to the nurse If God could only let me live long enough to put my daughter
through college, I wouldnt mind dealing with this illness. The nurse caring
for this client recognizes this statement as reective of which stage of
grieving?
(a) Denial
(b) Acceptance
(c) Bargaining
(d) Anger
95. The nurse on a psychiatric unit is caring for a client with paranoid
schizophrenia who has lost 15 pounds within the past three weeks. The client
accuses the staff of trying to poison all of the clients on the unit. Which
of the following nursing interventions would be a priority for the nurse to
include in the clients plan of care?
(a) Determine the clients favorite foods
(b) Offer the client small quantities of food at frequent intervals
(c) Sit with the client during meals
(d) Provide the client with pre-packaged foods that the client likes
29
96. The nurse is admitting a 20-year-old client with anorexia nervosa. The nurse
should assess the client for
(a) stained enamel of the teeth
(b) lanugo-type hair on the body
(c) persistent ringing in the ears
(d) white patches on the tongue
97. The nurse is admitting a client with major depression. It would be a priority
for the nurse to
(a) determine if the client was voluntarily admitted
(b) ask the client if suicide has been contemplated
(c) have the clients possessions searched for sharps
(d) administer to the client the prescribed antidepressant
98. The nurse is caring for a client with disseminated intravascular coagulation
(DIC) who is receiving a unit of packed red cells. Thirty minutes after the
start of the transfusion, the client reports chills and ank pain. The nurse
should rst
(a) ush the intravenous tubing with normal saline
(b) assess the clients vital signs
(c) stop the transfusion
(d) notify the primary health care provider
99. The nurse is developing a teaching plan for a client with pulmonary
tuberculosis who has been prescribed rifampin (Rifadin), isoniazid (INH),
pyrazinamide (Tebrazid) and ethambutol (Myambutol). The nurse should
include in the teaching plan that
(a) the combination of drugs prescribed is necessary to decrease the risk of
drug resistance
(b) the medications should be taken on an empty stomach
(c) the medications can be discontinued in one month
(d) the client will require hepatic function tests every month
30
100. The nurse is reviewing a clients arterial blood gas (ABG) results which
reveal the following: pH: 7.35; PaO2: 75 mm Hg; PaCO2: 55 mm Hg; HCO3: 30
mEq/L. The nurse should recognize that this result is suggestive of which
acid base imbalance?
(a) compensated metabolic acidosis
(b) compensated respiratory acidosis
(c) compensated metabolic alkalosis
(d) compensated respiratory alkalosis
101. The nurse in a well child clinic is taking the vital signs of a 4 year old client.
The nurse obtains the following readings: temperature 98.2F, pulse 110,
respirations 22, blood pressure 86/60. The nurse should
(a) ask if the parent knows what the childs pulse rate is usually
(b) encourage the child to rest for 10 minutes and reassess vital signs
(c) document the ndings in the clients medical record
(d) notify the primary health care provider of the ndings
102. A nurse has become aware of the following client situations. Which of the
following if observed shows that the UAP needs further teaching? The UAP
(a) avoids washing the body of a Jewish client until thirty minutes after death
(b) allows the family of a Buddhist client to chant ritual rites at the bedside
of their deceased father
(c) provides coffee and cookies for the visiting family of a Mormon client
(d) removes a cup of tea from the breakfast tray of a Seventh Day Adventist
client
103. A nurse has become aware of the following situations. Which should cause
the greatest concern for the nurse? A client with
(a) a bipolar disorder who is screaming at the nurses station
(b) congestive heart failure has bi-pedal edema
(c) a transurethral resection of the prostate (TURP) has blood tinged urine in
the urinary bag
(d) radon seed implants is seen ambulating in hall
31
104. The nurse is caring for clients who were recently removed from a falling
building. Who would the nurse see rst? The client with
(a) rst degree burns and a sprained left ankle
(b) dilated pupils and a small laceration to the left ear
(c) a fracture of the right tibia and abdominal pain
(d) confusion and soft tissue injuries
105. A nurse is preparing assignments for the day. Which of the following clients
should the nurse see rst? A
(a) 48 y.o ventilator dependent client who needs a sputum specimen
(b) 54 y.o on Bleomycin (Blenoxane) complaining of vomiting
(c) 65 y.o with pneumonia who needs to start IV antibiotics
(d) 72 y.o asthmatic complaining of SOB after using Albuterol (Ventolin)
106. A nurse working on a pediatric unit is made aware of the following
situations. Which child is the priority to be seen rst? A
(a) 1 year old with Tetralogy of Fallot with bluish discoloration to the lips
while crying
(b) 2 year old with renal failure with a potassium level of 6.4 mEq/L
(c) 3 year old diagnosed with Rheumatic Heart Fever with an elevated ESR rate
(d) 4 year old diagnosed with Rota-Virus having 5 bowel movements during an
8 hour shift
107. After receiving report from the night nurse, which of the following patients
should the nurse see rst?
(a) A 30- year old woman who is 38 weeks pregnant complaining of a small
amount of vaginal bleeding
(b) A 42- year old man with left sided weakness asking for assistance to the
commode
(c) A 55-year old woman complaining of chills who is scheduled for a total
abdominal hysterectomy
(d) A 77-year old man with a nasogastric tube who had a gastrectomy
yesterday
32
108. Which of the following clients is appropriate to assign to an LPN for

medication administration? *
(a) A 25 year old in sickle cell crisis who will need Morphine intravenously
(b) A 36 year old post operative client who is using a PCA pump
(c) A 50 year old who will need Regular Insulin coverage for a glucose reading
of 240mg/dl
(d) A 60 year old who needs Dopamine intravenously for blood pressure
management
109. The charge nurse is making assignments for the day. Which patient would
you assign to the RN oated from the Pediatric unit to the Emergency
Department? *
(a) A 2 year old admitted with suspected ingestion of chlorine
(b) A 5 year old being treated for Asthma that is not responding to
bronchodilators
(c) A 7 year old brought to the department following a motor vehicle accident
(d) A 10 year old awaiting admission following cast placement
110. The Charge nurse is making assignments for the day. The team consists of
the RN/LPN-LVN and UAP. Which client is appropriate to assign to the UAP? *
(a) The client who had a stroke 4 days ago with left sided weakness who
needs feeding
(b) The client who needs a Fleet enema administered prior to colonoscopy
(c) A recently admitted client who needs their vital signs taken
(d) A client who requires chest physiotherapy every shift
111. The nursing team consists of a RN/LPN and UAP. Which action should be
appropriately assigned to the LPN? *
(a) Bathing a child admitted with chickenpox
(b) Taking the vital signs of the recently admitted client
(c) Transporting a client to the chapel for noon time prayers
(d) Insertion of an indwelling catheter for a client with urinary retention
33
112. In providing care for a client being treated for uid volume excess, which of
the following interventions would be best delegated to an experienced UAP?
Select all that apply.*
(a) Monitor EKG readings
(b) Obtain vital signs every 30 minutes
(c) Check for the presence of pedal edema
(d) Insert IV line
(e) Document hourly urine output
(f) Measure weight
113. A mental health nurse is oated to work on the medical surgical unit. Which
client would be most appropriate to assign to the mental health nurse? A
client that:
(a) is 4 hours post operative following cholecystectomy
(b) has dehydration and needs IV uids
(c) has mechanical ventilation and needs to be suctioned
(d) is in traction for a broken femur
114. A nurse is caring for the following clients. Which client is the priority to be
assigned to a private room? A client with
(a) HIV
(b) Cirrhosis of the liver
(c) Scabies
(d) Pneumonia
115. A nurse is caring for the following clients. Which client is a priority to be
assigned to a private room? A client with
(a) Rubeola
(b) Rubella
(c) Klebsiella Pneumoniae
(d) Pediculosis
34
116. The nurse is caring for several clients requiring isolation. There is one
private room available on the unit. The nurse should place the highest
priority on assigning which of the following clients to the private room? The
client
(a) with fever and diarrhea for 2 days after taking antibiotics
(b) who is HIV + with a temperature of 101
(c) with low grade fever and night sweats
(d) with Leukemia whose temperature is 100
117. The infection control nurse is making rounds on a Medical Surgical unit.
Which of the following, if observed by the nurse requires immediate
intervention?
(a) A UAP is observed wearing gloves while emptying a urine drainage bag
(b) An RN is observed wearing a surgical face mask while caring for a client
with tuberculosis (TB) in a negative pressure room
(c) An LPN is observed wearing a gown and gloves while caring for a mentally
ill client with Clostridium Difcile toxin
(d) A RN is observed wearing a gown, gloves, and shoe covers while caring for
a client with Ebola Virus
118. The nurse should initiate protective precautions for the client who has
(a) Red Blood Cell Count (RBC) of 3,900/mm3
(b) Platelet count of 400,000/L
(c) Hemoglobin (Hgb) 9.0 g/dl
(d) White Blood Cell Count (WBC) 2,500/mm3
119. A nurse is caring for a client experiencing late decelerations. The
appropriate initial action by the nurse is to:
(a) change the clients position
(b) notify the health care provider in charge
(c) increase the Pitocin (Oxytocin) drip
(d) decrease the IV uid infusion
35
120. A nurse working in labor and delivery walks into the room of a client that
is 37- weeks-gestation and notices a prolapsed cord? The initial action of the
nurse should be to
(a) use a sterile glove to put cord back inside
(b) place the client in trendelenburg position
(c) use a dry sterile gauze to cover the cord
(d) initiate Leopolds Manuever to approximate the fetal position
121. A nurse in the prenatal clinic is caring for a client. The last normal
menstrual period was from May 3, 2008 to May 8, 2008. Calculate the
expected date of connement (EDC).
(a) March 15, 2009
(b) January 10, 2009
(c) February 10, 2009
(d) February 15, 2009
122. A nurse working in a clinic is doing teaching regarding sexually transmitted
Infections. The client cannot understand how syphillis was contracted
because there has been no sexual activity for several days. As part of
teaching, the nurse explains that the incubation period for syphilis is about:
(a) 1 month
(b) 1 week
(c) 2 - 3 weeks
(d) 2 - 4 months
123. A client is admitted to Labor and Delivery at 38 weeks gestation. The nurse
would be correct to state that the client is in the second stage of labor when
(a) the placenta is delivered
(b) bulging is seen in the perineum
(c) contractions are irregular
(d) rubra lochia is noted
36
124. A client on an inpatient psychiatric unit believes the staff is trying to poison
her. The nurse should:
(a) Explain that the staff is trust-worthy
(b) Allow the client see others eat their food
(c) Offer factory-sealed foods and beverages
(d) Taste the food in front of the client to prove it is edible
125. A nurse is caring for a client taking Thorazine (Chlorpromazine). Which
statement shows an understanding of instructions regarding this medication?
The client states
(a) I will take my pills every time I hear voices
(b) I will drink extra uid to prevent this dry mouth
(c) I will wear a wide brim hat up at the beach
(d) I will stop my medication when I feel better
126. An emergency room nurse is caring for a client with suspected phenobarbitol
use. Which of the following will result if the client has a barbituate addiction?
(a) Watery eyes, slow shallow breathing, frequent snifng
(b) Dilated pupils, shallow respirations, weak and rapid pulse
(c) Constricted pupils, respirations depressed, nausea, vomiting
(d) Sluggish pupils, increased respirations, decreased pulse
127. The nurse has attended a staff development conference on cultural
considerations for clients receiving hospice care. Which of the following
statements if made by the nurse would require follow up?
(a) The family of a client of Buddhist faith may ask for a priest to be present
at the time of death
(b) The family of a client of Jewish faith may request to have mirrors covered
after the death of the client
(c) The family of a client of Muslim faith may request that the body of the
client be turned to face the south east at the time of the clients death
(d) The family of a client of Hindu faith may request that the body be bathed
after their death
37
128. A nurse is caring for a client admitted with Lannecs cirrhosis. Which
vitamin supplement may be necessary to include?
(a) Vitamin B6
(b) Vitamin A
(c) Vitamin B1
(d) Vitamin C
129. A nurse is caring for a client with Celiac disease. Which of the following
statements shows that teaching has been effective?
(a) I enjoy eating oatmeal for breakfast.
(b) I dislike rice so it will be easy to avoid.
(c) I will have popcorn and juice while I am at the movies.
(d) I can have eggs with my rye toast.
130. The nurse is observing a client with renal failure select foods from the lunch
menu. Which of the following selections if made by the client would indicate
a need for further teaching?
(a) Haddock and spaghetti
(b) Cereal with buttermilk
(c) Corned beef and rice
(d) Orange juice with wheat toast
131. The nurse knows that the plan of care for a client with severe Ulcerative
Colitis would include which of the following?
(a) Low protein, high carbohydrate diet
(b) Low residue, high protein
(c) High protein, high residue
(d) High carbohydrate, high protein
132. The nurse is attempting to collect a stool sample for occult blood. Which of
the following foods should the client avoid prior to the test?
(a) Oranges
(b) Watermelon
(c) Bananas
(d) Kiwi
38
133. A client is performing quadriceps sets to strengthen the muscles used for
walking. When performing these exercises, the client contracts his quadriceps
with no change in muscle length and no joint movement. What term does the
nurse use to describe this type of exercise? __________________
134. A nurse is teaching a client to ambulate with crutches. The crutch gait the
nurse should teach a client after a single leg amputation is the:
(a) two point gait
(b) three point gait
(c) four point gait
(d) swing through gait
135. A nurse is preparing to give a dose of Bumex IV to an infant. The
prescription reads give 1mg/kg daily. If the infant weighed 6lbs, how many
mg should the infant receive?
___________________mg
136. An IV of Ringers Lactate 1,000 ml is to infuse over 8 hours. The drop factor
is 15gtt/ml. Calculate the rate of ow.
__________________gtt(s)/min
137. A client is to receive Dopamine (Intropin) 3 mcg/kg/min. The client weighs
185 pounds. The available dose is 400 mg per 500 ml D5NS. How many
milliliters should be administered each hour? (Round to the nearest tenth) *
______________________ml
39
138. A physician has selected a medication for a client with glaucoma that is to
be administered one time per week. Which of the following medications is a
direct acting parasympathomimetic agent used as a miotic in the treatment
of glaucoma?
(a) humorsol (demecarium)
(b) cyclogyl (cyclopentolate)
(c) pilocarpine (pilocar)
(d) timolol (timoptic)
139. The nurse is caring for a client taking the medication Clozaril (Clozapine).
Which of the following statements if made by the client shows that teaching
has been effective?
(a) I will increase my glucose intake.
(b) I should include bulk and uids in my diet.
(c) I should expect a decrease in my risk of infection.
(d) I must remember that hypertension is common.
140. A student nurse is preparing to administer Cardura (Doxazosin). Which of the
following should be included in teaching? Select all that apply.
(a) avoid driving
(b) expect increased libido
(c) double doses if one dose is missed
(d) continue to take cold remedies
(e) blurred vision may occur
141. The parent of a child taking Concerta (Methylphenidate) calls the clinic and
reports the following symptoms. The nurse knows which of the following is an
expected side effect?
(a) lethargy
(b) increased appetite
(c) weight gain
(d) metallic taste in the mouth
40
142. The nurse is caring for a 76 year old client whose past medical history
includes coronary artery disease. A review of the laboratory results
reveal: HDL 34, LDL 168 and total Cholesterol 270. Which of the following
medications might be included in the plan of care?
(a) Tagamet (Cimetidine) 300 mg po four times a day
(b) Coumadin (Warfarin Sodium) 2 mg po at bedtime
(c) Questran (Choleystyramine) 4 gms po every day
(d) Reglan (Metoclopramide) 10mg po as needed
143. A nurse is caring for a client who is complaining of muscle spasms and
rigidity. It would be a priority for the nurse to check which lab value?
(a) K+
(b) NA+
(c) Ca+
(d) Mg144. A nurse is caring for a client with Multiple Myeloma. The nurse would expect
abnormalities in which of the following lab values?
(a) ammonia
(b) red blood cells
(c) glucose
(d) potassium
145. A nurse is using the Glasgow coma scale to assess a client who had a head
injury. During assessment, the following is observed: Eyes open to speech,
motor response appropriate, client obeys commands, and conversation is
confused. The client should receive a score of:
(a) 3-5
(b) 6-10
(c) 11-13
(d) 14-15
41
146. The nurse is caring for a client who underwent surgical repair of a detached
retina of the right eye. Which of the following interventions should the nurse
perform? Select all that apply.
(a) place the client in the prone position
(b) approach the client from the left side
(c) encourage deep breathing and coughing
(d) discourage bending at the waist
(e) orient the client to his environment
(f) administer a stool softener as prescribed
147. The nurse is caring for a client with hypothyroidism. Expected ndings for
this disorder include: Select all that apply.
(a) Constipation
(b) Dry skin
(c) Anorexia
(d) Insomnia
(e) Bradycardia
(f) Palpitations
148. While doing a routine check up with the gynecologist, a 32 year old client
complains of frequent yeast infections. The nurse knows which of the
following may be noted?
(a) a fasting glucose of 132 mg/dl
(b) a white blood count of 10,000 cc mm
(c) a HGB (hemoglobin) of 15 mg/dl
(d) a BUN (blood urea nitrogen) of 19 mg/dl
149. A nurse is providing care for a client with Type I IDDM complaining of a
headache. What should the nurse do rst?
(a) Give one cup of orange juice
(b) Call the nurse in charge
(c) Check the clients glucose level
(d) Administer insulin as prescribed
42
150. The charge nurse was alerted about the need for multiple admissions
following a tornado. Which of the following clients would be appropriate for
the charge nurse to recommend for discharge? *
(a) A client with a T3 injury reporting headache
(b) A client with a chest tube that has continuous bubbling in the water seal
chamber
(c) The bipolar client with a Lithium level of 1.8 mEq/L
(d) The COPD client with an ABG reading of pH 7.34 PaO2 89 PaCO2 55 HCO3 23
43
Bonus Questions ( Hot Spot )

1. The nurse is assessing a clients pulses after a cardiac catheterization using
the femoral artery. In addition to the posterior tibial pulse place an X on the
other pulse site that should be assessed.
44
2. A child presents to the clinic with fever, lethargy, nausea, and vomiting, and
erythema. Erythema Infectiosum (Fifth Disease) is suspected. Place an X
where the nurse would expect the initial rash to appear.
45
3. The nurse is preparing to administer an intramuscular injection to an infant.

Identify the area that the injection should be administered.
46
4. A nurse is interpreting a rhythm on the cardiac monitor. Identify the area

which represents atrial depolarization.
5. A nurse has assessed an unresponsive adult victim and noted absence of

breathing and circulation. Indicate where the self adhesive electrode pads
should be placed in preparation for automated external debrillation.
47
6. A nurse is preparing to administer an injection. Identify the area known as the

dorsogluteal site for intramuscular injections.
48
7. Use an X to identify the area of the lungs where the chest X-ray is likely to
reveal inltrates in a client diagnosed with tuberculosis (TB).
49
Rationales
1. A. The normal potassium level is 3.5 5.0 mEq/L. Giving Kayexalate in
this situation may cause the client to lose potassium, causing hypokalemia,
therefore the drug is not indicated; the therapeutic level for Dilantin is
10 20 mcg/ml, a level of 8 is sub therapeutic thereby increasing the risk of
seizure activity. Acetaminophen can be safely prescribed to clients with ASA
sensitivity. Azithromycin (Zithromax) can be safely prescribed for clients with
sensitivity to Penicillin. Safe Effective Care Environment; Management of
Care
2. A. Informed consent, explanation and decision making must occur before
sedation is given; therapeutic interventions for retinal detachment include
bedrest with the area of detachment in a dependent position to promote
healing; the cast should be handled with the palms of the hands while wet to
prevent denting; a broad base of support is used during transfers to prevent
muscle injury. Safe Effective Care Environment; Management of Care
3. B. An adolescent with uncontrolled Diabetes Mellitus would require the
greatest number of disciplines (multidisciplinary) to manage their care
i.e. Medicine, Nursing, Social Work, Nutritionist; the other choices do not
require as many providers of care to meet their needs. Safe Effective Care
Environment; Management of Care
4. C. The management of a client following abdominal surgery is standard. The
postpartum nurse routinely cares for mothers following caesarean section;
therefore it is appropriate to assign this client; The other choices are not
appropriate to assign to this nurse. Safe Effective Care Environment;
Management of Care
5. D. A child experiencing normal growth and development should be ambulating
independently by 12 months; the Babinski reex disappears after 2 years
of age; an infant typically holds their own bottle by 6 months; stranger
anxiety usually develops at approximately 7 months. Safe Effective Care
6. C. Consent for organ donation is given by a clients next of kin in the absence
of an Advance Directive. Safe Effective Care Environment; Management of
Care
7. C. The client admitted with Guillain-Barre Syndrome should be assessed
rst because of the possibility of rapid progression of this illness and
50
neuromuscular respiratory failure; clients with COPD are likely to have pulse
oximetry readings of 90% related to chronic hypoxia; this client along with the
other two choices are important, but not the priority. Safe Effective Care
8. B. The Certied Nursing Assistant may be assigned to a client that requires
one- to-one observation for safety; the other choices require skilled nursing
intervention by a LPN (Licensed Practical Nurse) or RN (Registered Nurse).
Safe Effective Care Environment; Management of Care
9. A. To maintain condentiality the nurse should not discuss the clients
diagnosis with family members; it is advisable that two nurses review the
prescription for blood transfusion to identify the client, blood type, Rh factor,
expiration date and the blood numbers; interrupting staff members discussing
a client in a public place should be done to maintain client condentiality;
collaborating with the nutritionist is an appropriate nursing intervention. Safe
Effective Care Environment; Management of Care
10. A. Putting a client in a geriatric chair with the lap tray in front of them
restricts movement which constitutes false imprisonment; choice B is
an example of assault not battery; C is an example of negligence not
malpractice and D is an example of battery not assault. Safe Effective Care
11. C. Vomiting and diarrhea can be managed on a non-emergent basis; clients
reporting indigestion may be experiencing a cardiac event; clinical
manifestations suggestive of abdominal aortic aneurysm include abdominal
mass and abdominal throbbing; the client who is 6 weeks pregnant
experiencing abdominal pain must be evaluated to rule out ectopic pregnancy
which could be life threatening. Safe Effective Care environment;
Management of Care
12. D. Following cardiac catheterization using the femoral artery, the client
remains on bedrest for 2 to 6 hours with the affected leg straight and the
head of the bed elevated to 30 degrees; blood tinged sputum is an expected
nding after bronchoscopy; removal of uid from the peritoneal cavity as in
paracentesis will result in decreased abdominal girth; post lumbar puncture
headache ranging from mild to severe may appear a few hours to days
following the procedure. Safe Effective Care Environment; Management of
Care
51
13. D. Clients with a history of complex partial seizures may black out for one
to three minutes. They experience automatisms (the client is not aware
of the behavior) such as lip smacking, patting, and picking of the clothes.
This client should be seen rst; dribbling, urinary frequency and burning on
urination may be expected after an indwelling catheter is removed; exion
and extension of the neck is contraindicated with cervical traction; returning
the confused client with Alzheimers disease to their room is not a priority.
14. B. Oatmeal is contraindicated for children with Celiac disease. These clients
should be on a gluten free diet. Foods to be avoided include barley, rye, oats
and wheat; the other choices are permissible as a part of the dietary plan.
15. C. A sterile glove, not clean, should be used on the dominant hand during
tracheal suctioning to prevent infection; the apical pulse should be assessed
for one full minute prior to the administration of Digoxin (Lanoxin); elevation
of the stump following amputation is performed for the rst 24 hours only
to prevent hip or knee exion contracture; clients should be positioned on
the operative side to promote lung expansion of the unaffected lung. Safe
Effective Care Environment; Management of Care
16. A. The newborn should be placed in a rear facing car seat with appropriate
restraints until about one year of age and at least 20 pounds; the lap portion
of the shoulder belt should be positioned snug around the hips, never the
abdomen; all children under the age of 12 should be placed in the rear seat of
the vehicle. Safe Effective Care Environment; Safety and Infection Control
17. A. Vancomycin resistant enterococcus (VRE) is spread by direct contact;
disease that are transmitted by droplets (sneezing, coughing) include
inuenza, pneumonia, streptococcal pharyngitis; protective isolation
precautions are used for persons with suppression of the immune system;
airborne precautions are instituted for diseases transmitted via the air such
as measles (rubeola), tuberculosis (TB), and varicella (chickenpox). Safe
Effective Care Environment; Safety and Infection Control
18. D. Use of a gown to prevent contact with the client or client contaminated
items is desired; a particulate respirator mask and negative pressure room is
used during the care of someone with tuberculosis; prohibition of owers and
live plants is necessary for the client on protective precautions to prevent
infection. Safe Effective Care Environment; Safety and Infection Control
52
19. D. A white blood cell count of 2,500/mm3 is low therefore the client is at risk
for infection. Protective precautions should be implemented. The normal
White blood cell count (WBC) is 5,000 10,000/mm3; The normal red blood
cell count (RBC) is 4 5 million/mm3, a decit of red blood cells is indicative
of anemia. The normal platelet count is 150,000 400,000/Liter. A low
platelet count predisposes the client to bleeding; the normal hemoglobin
value is 13.5 18g/dl for males and 12 -16g/dl for females. A low hemoglobin
is suggestive of anemia and possible active bleeding. Safe Effective Care
Environment; Safety and Infection Control
20. A. Client teaching of HIV infected individuals should include avoidance of bird
droppings and soil to prevent the opportunistic infections toxoplasmosis and
cryptococcosis; avoiding crowds, not working in the garden and increasing
protein in the diet are important for the maintenance of health; these clients
do not need further teaching. Safe Effective Care Environment; Safety and
Infection Control
21. D. After a disaster clients are seen in order of priority. Those with life
threatening injuries who are likely to survive are seen rst (Class 1; Priority
1). Those that require immediate care, who can be evaluated within 2 hours,
are seen next (Class II; Priority 2). Next are clients who could wait hours to
days before treatment (Class III; Priority 3). The client in choice C is the most
seriously injured and not likely to survive, they would be seen last (Class IV;
Priority 4). That person should be separated from others but not abandoned.
Safe Effective Care Environment; Safety and Infection Control
22. B. Cleansing of the wound from the outer surface to the inner surface is
incorrect technique. Wounds should be cleansed in an outward direction
to avoid transferring organisms from the surrounding skin into the wound.
Choices A, C, and D follow the principles of infection control, follow up is not
required. Safe Effective Care Environment; Safety and Infection Control
23. B. The treatment of rheumatoid arthritis is aimed at relieving pain. NSAIDs
(Non steroidal anti-inammatory drugs) are customarily the rst type of agent
used; the other agents listed are used later in the management process.
Physiological Integrity; Pharmacological and Parenteral Therapies
24. C. An infant at 2 months of age should have developed a social smile; at 4
months head control is gained; the 5 month old loses the tonic neck reex
and is able to turn from prone to back. Health Promotion and Maintenance
53
25. C. Solids may be introduced by approximately 6 months of age. Rice cereal

is usually introduced rst with the addition of fruits, vegetables then meats
at a rate of one new food per week to monitor for allergic reactions. Solids
should be pured, strained or mashed; Honey is avoided in infancy due to the
risk for infant botulism; whole milk is not introduced until after one year of
age. Physiological Integrity; Basic Care and Comfort
26. C. The child with thrombocytopenia needs to be protected from injury
secondary to the risk of bleeding. Use of a board game, a quiet activity
provides diversion and challenges that is developmentally appropriate while
eliminating the risk of injury; nger paints is applicable to a preschool client;
the ball and bat is avoided to prevent injury; the stuffed toy may be offered
to the toddler. Health Promotion and Maintenance
27. A. The child experiencing fever and hypotension should be seen rst, they
are at the highest risk in this situation for decompensation; the average blood
pressure for a toddler is 92/56; the child with asthma is not acutely ill at this
time; pain is expected with a bone fracture, management of pain is important
but does not take priority; ulcerative colitis is expected to produce 10 20
bloody stools per day, this is not the priority in this situation. Safe Effective
Care environment; Management of Care
28. B. The parent should be taught the ESSR (Enlarged nipple, Stimulate Suck by
rubbing the nipple on the lower lip, Rest after each swallow to allow infant to
complete swallowing) method of feeding to decrease the risk of aspiration;
the infant should be fed in an upright position; prone position and paciers
should not be used. Physiological Integrity; Physiological Adaptation
29. C. According to Sigmund Freud, the phallic stage occurs between 3 6 years
of age. During this stage the child experiences unconscious sexual attraction
to the parent of the opposite sex. This is called the Oedipal Complex. The
statement is reective of this stage of development. The other choices are
not correct actions. Safe Effective Care environment; Management of Care
30. D. Coarctation of the aorta is characterized by narrowing of the aorta. As
a result of this narrowing, absent femoral pulses, poor weight gain and
increased blood pressure in the upper extremities are expected ndings. A
high pitched murmur is not present. Physiological Integrity; Physiological
Adaptation
31. B, C, and F. Children experiencing acyanotic defects may experience
tachycardia, tachypnea and delay in growth and development; poor suck
54
reex, bradycardia, and fainting spells are indicative of cyanotic defects.

Physiological Integrity; Physiological Adaptation
32. C. Safety data from several studies show that acellular pertussis vaccine
cause fewer adverse reactions than whole-cell vaccines. Pre-term infants
generally do not wait 6 months before beginning vaccinations; the rst
Hepatitis B vaccine is given at birth; the Haemophilus inuenzae type b (HIB)
is given at 2 months, 4 months, and 6 months and between 12 15 months.
Health Promotion and Maintenance
33. D. Pyloric Stenosis is hypertrophy of the muscles of the pylorus causing
narrowing of the pyloric canal between the stomach and duodenum. A
characteristic olive shaped mass may be palpated in the epigastrium to the
right of the umbilicus. Intussusception is characterized by currant jelly
stools. Hirschprungs disease (congenital mega colon) results in ribbonlike foul smelling stools; a child with an umbilical hernia has swelling or
protrusion around the umbilicus that is reducible. Physiological Integrity;
Physiological Adaptation
34. B. By the age of 3, a toddler should be able to ride a tricycle independently;
the preschool child is not able to discriminate between fantasy and reality.
This is the developmental task of a school age child; at 3 years of age the
vocabulary is at about 900 words; cooperative play with the incorporation
of imaginary friends is common in this age group. Health Promotion and
Maintenance
35. C, D, and E. All of these tasks are within the job description of a Certied
Nursing Assistant and can be safely delegated; A, B, and F would require
assessment, nursing intervention and patient education which is the role of
the nurse. Safe Effective Care environment; Management of Care
36. C. Clients being treated with Zidovudine (AZT) should have routine monitoring
of CBC (complete blood count), hepatic and renal function studies.
Physiological Integrity; Physiological Adaptation
37. D, C, A, and B. Inspection is done rst. Auscultation is performed before
percussion and palpation to decrease the risk of stimulating the bowel which
could result in false positive ndings. Health Promotion and Maintenance
38. B. The presence of calf pain postoperatively is suggestive of the development
of DVT (deep vein thrombosis) which is a potentially life threatening post
operative complication of clients undergoing gynecologic surgeries. This client
55
should be seen rst; the other situations are not the priority in this situation.
Safe Effective Care environment; Management of Care
39. 21 gtts/min. Volume
(1000ml)
X
Drip factor (10gtts/ml)
Time in minutes (8hours x 60 minutes)
40. 30 ml. Desired amount (20mEq) X Quantity (15ml)
Amount on hand (10 mEq)
41. A, E, and F. Heparin is best absorbed from the abdomen; aspiration and
massaging the site after injection is contraindicated, a 26 27 gauge 5/8 inch
to inch needle is used; the antidote for heparin is Protamine Sulfate. The
correct dosage to be administered is
0.66ml. Desired amount 5,000 units X Quantity (1ml)
Amount on hand 7,500 units
42. D. It is customary in the Hindu faith that only family members touch the body
after death. The other statements are correct. Follow up is not necessary.
Psychosocial Integrity
43. C. The client receiving Lithium (Eskalith) should be careful to include sodium
in the diet to prevent hyponatremia which predisposes the client to Lithium
toxicity; Caffeine should be avoided because of the diuretic effect which will
further increase the risk of hyponatremia; There is no contraindication for
fresh fruit or raw vegetables. Psychsocial Integrity
44. C. These fruits are rich in potassium. They should be included in the diet to
prevent hypokalemia. Hypokalemia, hypercalcemia, and hypomagnesemia
predispose the client to Digoxin (Lanoxin) toxicity; the other statements
are true of Digoxin therapy. Physiological Integrity; Pharmacological and
Parenteral Therapies
45. A. Bumex is a potassium depleting diuretic. Apricots are a source of
potassium; organ meats, sardines and are not a source of potassium;
apples contain a low quantity of potassium. Physiological Integrity;
Pharmacological and Parenteral Therapies
46. B, D, and E. is true of ulcerative colitis; steatorrhea is common in cystic
brosis clients; A diet low in residue (not high) is recommended to minimize
symptoms; eating small frequent meals and lying down after eating are
56
interventions used to prevent dumping syndrome. Physiological Integrity;

47. A. The nurse veries nasogastric tube placement by instilling 30cc of air
into the feeding tube while auscultating over the stomach for bowel sounds;
uids are not introduced because of the risk of aspiration if the tube is
malpositioned. Safe Effective Care Environment; Safety and Infection
Control
48. C. Placing a client in prone position after above the knee amputation is done
to prevent contractures; following supratentorial surgery the head of the
bed is elevated 30 degrees to promote venous outow. Removing all liquids is
not necessary for clients experiencing Dumping Syndrome. The client should
be taught to avoid drinking with meals. Safe Effective Care Environment;
Safety and Infection Control
49. B. Assessing whether or not the child took these medications in the past
will help to determine if an allergic reaction occurred; the recommended
pediatric dose for ampicillin (Omnipen) is 50mg/kg/day; mixing the
medication with apple sauce will help to make it palatable to the child; it
is not necessary to wait for throat culture result, however the nurse should
obtain the culture before giving the rst dose of antibiotic. Physiological
Integrity; Pharmacological and Parenteral Therapies
50. B. It is important that the child with sickle cell anemia avoid other children
with infections because infection could precipitate a sickle cell crisis; cold
water is contraindicated to prevent vasoconstriction; aspirin is avoided in
large doses due to the risk of metabolic acidosis; contact sports should be
avoided. Physiological Integrity; Reduction of Risk Potential
51. A. At 5 months old the typically developing infant should be able to roll
from abdomen to back; sitting without support as well as hand dominance
is expected at 7-9 months; imitative speech should develop between 10-12
months of age. Health Promotion and Maintenance
52. B. Giving away ones belongings could be an indication that this client is
suicidal and has made a plan to end their life; this client is the priority to
ensure safety. One-to-one observation may be needed. Safe Effective Care
environment; Management of Care
53. B. Antacids should not be administered at the same time with iron
preparations because absorption is inhibited; to enhance the antacid effect
Maalox (aluminum hydroxide/magnesium hydroxide) is administered 1-3
57
hours after meals and at bedtime; shaking the medication and assessing
for the presence of gastric pain is applicable. Physiological Integrity;
54. D. Vitamin B6 is not used in the management of macular degeneration; clients
who have had gastrectomy may require Vitamin B 12 supplement secondary
to the absence of intrinsic factor; Vitamin D is necessary for the proper
absorption of calcium; yellow vegetables such as squash, pumpkin, and
carrots are good sources of Vitamin A. Physiological Integrity; Basic Care
and Comfort
55. A. Statements made by the mother of the infant sleeping for prolonged
periods support the diagnosis. Follow up is needed for diagnostic workup to
conrm this disorder. Signs of congenital hypothyroidism include lethargy,
poor feeding, constipation and bradycardia; high pitched cry is not suggestive
of hypothyroidism; frequent loose stools and brisk reexes may be indicators
of hyperthyroidism. Physiological Integrity; Physiological Adaptation
56. C. Syrup of Ipecac is not indicated in this situation as it will induce vomiting
which could lead to further damage of the gastric mucosa by the bleach. Safe
57. A, C, E, F. The high pressure alarm on the ventilator is triggered with
increased pressure in the system (obstruction) as in kink in the tubing,
increased bronchial secretions, during acute bronchospasm and biting of the
tube by the client; the other choices would cause the low pressure alarm to
sound. Physiological Integrity; Reduction of Risk Potential
58. C. During the initial post operative period, the stoma is red moist and slightly
swollen. These are normal ndings that should be documented; petroleum
jelly is not applied to the stoma. Physiological Integrity;Physiological
Adaptation
59. D. Multiple Sclerosis is not managed using IV IgG. Common medications
that may be prescribed are Avenox (Interferon beta 1a), Betaseron
(Interferon beta 1b), Copaxone (Glatiramer), and Rebif (Interferon beta 1a);
Corticosteroids are used to limit the severity and duration of exacerbations;
the other options are correct statements for those neurological disorders.
Physiological Integrity;Physiological Adaptation
60. C. Assistive listening devices are not routinely required for clients with
Menieres disease. Most clients respond well to treatment with a low
sodium diet and medications like Meclizine (Antivert); the other options
58
are true of this condition, follow up is not necessary. Physiological

Integrity;Physiological Adaptation
61. B. Reports of loss of peripheral vision, rapid decrease in the visual elds,
acute eye pain and halos around the lights are symptoms associated with
closed angle glaucoma; clients with macular degeneration experience loss of
central vision; senile cataracts is manifested by blurred vision and decreased
color perception; pain or redness is not associated with age related cataract
formation; retinal detachment produces sudden ashes of light (photopsia) or
oating dark spots in the affected eye. Physiological Integrity;Physiological
Adaptation
62. D. Key features of left ventricular failure include wheezing or crackles in the
lungs, dyspnea, hacking cough and fatigue; pedal edema and jugular venous
distention is associated with right ventricular failure; oxygen saturation
of 95%-100% is a normal nding. Physiological Integrity; Physiological
Adaptation
63. C. NPO is not required prior to an EEG. The client is allowed to have breakfast
if prescribed. Caffeine and other stimulants should be avoided for 24 hours
prior to the procedure; the other statements are true of those diagnostic
tests, therefore follow up is not required. Physiological Integrity; Reduction
of Risk Potential
64. B. Transphenoidal hypophysectomy is the surgical removal of the pituitary
gland through the sphenoid sinus. Patient teaching includes avoidance of
any activity that raises intracranial pressure; bedrest is indicated following
radium implants; foods high in sodium are encouraged for clients on Lithium
(Eskalith) therapy to prevent hyponatremia which predisposes the client
to Lithium toxicity; postoperative positioning following a repaired retinal
detachment is on the operative side. Safe Effective Care Environment;
Safety and Infection Control
65. A. Foods containing oxalate should be restricted to prevent recurrent renal
stones. Examples of these foods are spinach, rhubarb, strawberries, tea,
peanuts and wheat bran. Physiological Integrity; Basic Care and Comfort
66. D. Hyperkalemia can result in serious adverse effects to excitable tissues
especially the heart, causing altered cardiac function; the BUN and creatinine
are elevated prior to dialysis due to increased circulating wastes in the blood
stream; a sodium level of 145 mEq/L is within the normal range of 135-145
mEq/L. Physiological Integrity; Reduction of Risk Potential
59
67. A. Female clients with new onset diabetes mellitus may report recent major
or minor infections particularly vaginal yeast infections; elevations in white
blood cell count, hemoglobin and blood urea nitrogen are not the priority in
this situation. Physiological Integrity; Reduction of Risk Potential
68. A. Testicular cancer is most common in males 15-35 years of age. Health
Promotion and Maintenence
69. B. Erikson states that the adult over the age of 65 goes through the
developmental stage of ego integrity vs. despair. This client is experiencing
despair secondary to the diagnosis of breast cancer; the school age child
experiences industry vs. inferiority; generativity vs. stagnation is present in
the middle aged adult; intimacy vs. isolation is associated with the young
adult. Health Promotion and Maintenence
70. C. Demadex (torsemide) is a potassium depleting diuretic; client education
should be done to include foods high in potassium to prevent hypokalemia;
Midamor (amiloride), Aldactone (spironolactone) and Dyrenium (triamterene)
are all potassium sparing diuretics; the nurse would limit foods containing
potassium with use of these medications. Physiological Integrity;
71. B. Calan SR is a sustained release medication, it should never be crushed,
chewed or broken; Cozaar (Losartan) is prescribed to control hypertension.
Clients taking antihypertensives should avoid sudden position changes to
prevent orthostatic hypotension; clients taking Captopril (Capoten) need
to avoid the use of salt substitutes secondary to the risk of hyperkalemia.
72. A. Sleep disturbances is characteristic of bromyalgia related to severe
exhaustion. Other manifestations are pain, muscle stiffness and spasms with
sensory changes; risk of infection, uid volume decit and urge incontinence
is not associated with bromyalgia. Physiological Integrity; Physiological
Adaptation
73. D. HPV (human papilloma virus), not Chlamydia is the sexually transmitted
infection linked with cervical cancer; the other statements are accurate, they
do not need follow up. Physiological Integrity; Physiological Adaptation
74. A. The N95 particulate respirator mask is required by the nurse entering the
room of the client being treated for TB. A surgical mask does not protect
against transmission, however during transport out of the room the surgical
mask should be placed on the client; varicella zoster requires droplet
60
precautions which include closing the door; RSV (respiratory synctival virus)
is spread by direct contact with a contaminated client or contaminated
object. Supplies are left in the clients room for their use only; Ebola virus is
present in all body uids, wearing a gown, mask and gloves are necessary to
prevent exposure and spread. Safe Effective Care Environment; Safety and
Infection Control
75. B. This clients care requires involvement of various members of the health
care team (multidisciplinary) i.e. nursing, medicine, OB/GYN, social worker,
nutritionist; the other clients do not need as many health care workers for
the provision of care. Safe Effective Care Environmen ; Management of
Care
76. B. The normal fetal heart rate (FHR) is 120-160 beats per minute, however
the client who has a consistent FHR of 132 beats per minute should be seen
rst to assess for fetal distress. There should be a uctuation of the heart
rate 6-25 beats per minute which indicates a well oxygenated and functioning
central nervous system; the other choices are not the priority in this
situation. Safe Effective Care Environment; Management of Care
77. C. Reports of swelling in the calf 8 hours postpartum may be suggestive of
the development of a deep vein thrombosis, a potentially life threatening
condition. Immediate intervention is needed; other symptoms include pain,
warmth, chills, diminished peripheral pulses, erythema, or shiny white skin
on the extremity. Safe Effective Care Environment ; Management of Care
78. B. Clients undergoing myelogram should be hydrated for at least 12 hours
before the test. This client needs follow up for further teaching. Safe
Effective Care Environment ; Management of Care
79. B. When climbing the stairs the client is taught to step up with the unaffected
leg while putting weight on the crutch handles. The elbows should be exed
at a 20-30 degree angle with avoidance of pressure under the arm to prevent
damage to the axillae nerve; placing both crutches on the unaffected side is
the correct technique when sitting down. Physiological Integrity; Basic Care
and Comfort
80. C. Fat embolism, a serious complication of fractures of long bones is
manifested by petechiae (a ne rash) over the chest, neck, upper arms or
abdomen, tachycardia, tachypnea, fever and respiratory distress. This client
should be evaluated rst. Safe Effective Care Environment ; Management
of Care
61
81. D. Aloe Vera is effective as an inammatory agent for soft tissue injuries,
burns, and abrasions; St. Johns Wort is helpful with menstrual disorders,
depression and as a diuretic; Kava Kava may be used to decrease anxiety and
stress; Dong-Quai is a smooth muscle relaxant used to regulate menstrual
periods, treat symptoms of premenstrual syndrome and cleanse the blood.
82. B. The proper technique to be used when teaching a client to ambulate
with a cane is to hold the cane in the hand opposite the affected leg.
Physiological Integrity; Basic Care and Comfort
83. B. The pulse oximeter and all other metals objects should be removed
before the client enters the room where the MRI is to be performed. Metal
containing objects are attracted to the magnetic eld and may cause injury.
84. D. optimal levels of glycosylated hemoglobin (HbA1c) is 4%-6% which indicates
consistent glycemic control. Levels over 8% indicate poor control and require
follow up; normal LDL is less than 130mg/dl; normal sodium is 135mEq145mEq/L; the normal WBC is 5-10,000L however a client with rhino sinusitis
(infection) would be expected to have a slightly elevated WBC. Physiological
Integrity; Reduction of Risk Potential
85. C. Cracked nipples are not a contraindication to breast feeding. The mother
should be instructed to expose the nipples to air for 10-20 minutes after
feeding, rotate the position of the baby for each feeding and ensure that
the baby is latched on to the areola not just the nipple. Safe Effective Care
86. B, A, D, C. The American Heart Association recommends this sequence of
CPR for an adult to provide rescue support and maintain some oxygen and
blood ow to the heart and brain. Physiological Integrity; Physiological
Adaptation
87. C. The client with Tuberculosis (TB) is placed on airborne precautions which
include placement in a negative pressure room with the door closed and use
of a particulate respirator mask; a gown and gloves are not needed when
talking with the client or taking the blood pressure; droplet precautions are
used for meningitis, HIB (haemophilus inuenzae type b), mumps, rubella,
pertussis and epiglottitis. Physiological Integrity; Physiological Adaptation
88. D. The priority in this situation is client safety. The nurse should be relieved
of their assigned clients since these behaviors suggest that the nurse may be
62
impaired; the charge nurse should not confront the other nurse. Instead, a
clear factual description of the situation should be documented then reported
to the nursing supervisor. Safe Effective Care Environment; Safety and
Infection Control
89. B. When responding to a re, there are four sequential priorities that must
be followed: Rescue the clients, which was done in this situation, Alarm (call
for additional help), Conne the re, Extinguish the re. Safe Effective Care
Environment; Safety and Infection Control
90. C. Reporting of suspected child abuse and maltreatment is mandated by most
states. The goal is to protect the child from further abuse. Documentation
should be clear and objectivethe record may be subpoenaed in court. Safe
91. B. Cocaine use is often associated with the presence of hallucinations,
tachycardia and respiratory depression. Untreated, this client is likely to
die, they are the priority in this situation; attention decit disorder, use of
Antabuse (disulram) or anticholinergic drugs do not produce hallucinations.
92. A. A client in the manic phase of bipolar disorder may have difculty meeting
nutritional needs because of their inability to sit still; competitive games
are avoided because the client is hyperactive, impulsive and distractible.
Structured activity is more appropriate; foods containing tyramine are
avoided in clients prescribed MAO inhibitors; placing the client on suicide
observation may be indicated during the depressed phase. Psychosocial
Integrity
93. A, E, and F. A- Elavil is given with or immediately after meals to minimize
gastric upset; E- Dry mouth is a possible adverse effect when using this drug.
Instruct client to increase uid intake if not contraindicated, or use sugarless
gum or candy to diminish dry mouth; F-Photosensitivity is a possible adverse
effect. Caution the client to use sunscreen and protective clothing; B, C
and D are not correct; Clients taking this drug are likely to experience an
increased appetite. Teach to monitor food intake to prevent undesired weight
gain; the medication should not be administered in the morning because of
the side effects; hypotension is associated with this drug, not hypertension.
Physiological Integrity; Reduction of Risk Potential
94. C. During the bargaining stage the client attempts to negotiate to prolong
their life. Kbler-Ross identied the stages of death and dying as denial
63
(disbelief), anger (hostility), bargaining, depression (sadness) and acceptance

(coming to terms with death). Psychosocial Integrity
95. D. The client experiencing paranoia is suspicious of the people around them
so they may elect not to eat causing alteration in the nutritional status.
Providing pre packaged foods will diminish the clients fear of being poisoned
by the staff. The other choices are helpful to the paranoid person but not a
priority. Psychosocial Integrity
96. B. Lanugo type hair on the body is a characteristic of anorexia nervosa;
stained enamel of the teeth is associated with bulimia nervosa related to the
frequent vomiting; persistent ringing in the ears and white patches on the
tongue are not associated with anorexia nervosa. Psychosocial Integrity
97. B. Asking about suicidal thoughts or plans is a priority when caring for the
depressed client. The person may not volunteer this information without
being asked. If the client answers yes, further assessment is required and
suicide precautions initiated. Psychosocial Integrity
98. C. Chills and ank pain are symptoms of a blood transfusion reaction. The
rst action by the nurse is to stop the transfusion; assessment of vital
signs is important but not done rst. The intravenous tubing is not ushed
with normal saline because the remaining blood in the line will be infused.
Instead, the nurse would change the entire intravenous set up then infuse
normal saline to maintain patency of the IV. Notication of the primary
health care provider must also occur. Physiological Integrity; Physiological
Adaptation
99. A. Drugs are prescribed in combinations of two or three anti-tuberculin
agents to decrease the risk of drug resistance. Isoniazid (INH) is usually the
primary drug; these medications may be given with food to minimize G.I.
upset; they are taken for 9-12 months to ensure eradication of the organism;
the client should be taught to have blood drawn to monitor hepatic function
every 2-4 weeks during therapy due to the risk of hepatotoxicity while taking
these drugs. Physiological Integrity; Pharmacological and Parenteral
Therapies
64
100. B. The normal pH is 7.35-7.45; the normal pCO2 is 35-45 mmHg. The normal
HCO3 is 22-26 mm Hg. The normal PaO2 is 80 100. With respiratory acidosis
there is an increase of carbon dioxide. Generally the renal and pulmonary
systems compensate for each other to return the pH to normal. In this
situation, the kidney increased the retention of HCO3 to normalize the pH.
Study Tool
Arterial Blood Gas
Normal range
Respiratory
Acidosis
Respiratory
Alkalosis
Metabolic
Acidosis
Metabolic
Alkalosis
pH 7.35-7.45
pCO2 35-45mm Hg
or norm
or norm
HCO3(bicarbonate)
22-26 mm Hg
or
norm
or norm
When the PH is within normal range and the pCO2 and or HCO3 are not,
consider compensation. Physiological Integrity; Physiological Adaptation
101. C. These ndings should be documented in the medical record as they are
within normal guidelines for the preschool child. A, B and D are not indicated
since the vital signs are within normal range. Physiological Integrity;
102. C. The statement further teaching indicates you are looking for an incorrect
response. Clients of the Mormon faith abstain from alcohol, coffee, and
tea. Choices A, B, and D are correct. Safe Effective Care Environment;
Management of Care
103. D. A client with radon seed Implants should be on absolute bed rest in
a private room to avoid emission of radioactive material. Clients should
also avoid infants and pregnant women. Choices A, B, and C. are expected
ndings. Safe Effective Care Environment; Management of Care
104. D. Confusion is the rst sign of increased intracranial pressure and or
hypoxia. According to disaster triage choices A and C are considered (priority
level 3) and choice B is a (priority level 4) which are lower priorities. Safe
Effective Care environment; Management of Care
65
105. D. Albuterol is a short acting bronchodilator which should improve

breathing. If there is no change in respiratory effort, this client is the priority.
Safe Effective Care environment; Management of Care
106. B. The normal potassium level is 3.5-5.5 mEq/L. Hyperkalemia places the
client at risk for arrythmias. This infant is the priority. Choices A, C, and D
are expected ndings. Safe Effective Care environment; Management of
Care
107. C. Chills may indicate a temperature elevation. According to the nursing
theorist Orem a client with an infection has an Air need. This client should be
seen rst. Safe Effective Care environment; Management of Care
108. C. Care of the client requiring insulin administration is appropriate for
the LPN. Choices A, B, and D, may require assessment and are therefore
more appropriate to delegate to the RN. Safe Effective Care environment;
Management of Care
109. D. This client is stable and appropriate for management by the pediatric
nurse. Choices A, B, and C are unstable and should be cared for by the
emergency room nurse. Safe Effective Care environment; Management of
Care
110. B. This choice is the most appropriate to delegate to a UAP. Choices A and D
are stable clients and can be seen by an LPN. Initial vital signs should be done
by an RN. Safe Effective Care environment; Management of Care
111. D. Choices A and C would be most appropriate to delegate to a UAP. Choice
B requires assessment and should be seen by the RN. Safe Effective Care
112. B, E, F are correct. Choices A, C, and D should be done by a nurse. Safe
Effective Care environment; Management of Care
113. B. Administration of intravenous uids has a predictable outcome. A, D
and C require the more experienced med-surg nurse. Safe Effective Care
66
114. D. Bacterial Pneumonia requires droplet precautions Viral Pneumonia needs

standard. The type of pneumonia is not specied. As a result, this client
should be isolated. A client with HIV and cirrhosis of the liver do not require
automatic isolation. A client with Scabies requires contact precautions which
would not take priority over droplet precautions if sufcient isolation rooms
were not available. Safe Effective Care Environment; Safety and Infection
Control
115 A. Rubeola requires airborne isolation which is the priority. Rubella requires
droplet precautions. Klebsiella Pneumoniae and Pediculosis require contact
precautions. Safe Effective Care Environment; Safety and Infection
Control
116. C. A client with low grade fever and night sweats is exhibiting signs of
tuberculosis (TB). TB requires airborne isolation. Choices A and B do not
require a private room. A client with leukemia may require a private room
if they are immunosuppressed. However, they would not take priority over
a client with TB. Safe Effective Care Environment; Safety and Infection
Control
117. B. CDC guidelines mandate the use of a N95 respirator mask prior to entry
into a room with a client on airborne precautions. The surgical mask is
appropriate when coming within 3 feet of the person on droplet precautions.
118. D. A white blood cell count of 2,500/mm3 is low therefore the client
is at risk for infection. Protective precautions should be implemented.
The normal White blood cell count (WBC) is 5,000 10,000/mm3; The
normal red blood cell count (RBC) is 4 5 millioion/mm3, a decit of red
blood cells is indicative of anemia. The normal platelet count is 150,000
400,000/Liter. A low platelet count predisposes the client to bleeding;
the normal hemoglobin value is 13.5 18g/dl male and 12 -16g/dl female.
Low hemoglobin is suggestive of anemia and possible active bleeding. Safe
67
119. A. The clients position should be changed initially to see if the FHR
tracing improves. Choices B, C, and D are not indicated at this time. Health
Promotion and Maintenance
120. B. Trendelenburg or knee chest positions are the most appropriate positions
for a client with a prolapsed cord. Choices A, C, and D are incorrect. Health
Promotion and Maintenance
121. C. Subtract 3 months and add 7 days to the rst day of the last normal
menstrual period (LNMP). Add one year if the pregnancy occurs in April
through December. Health Promotion and Maintenance
122. C. The time between infection with syphilis and the start of the rst
symptom can range from 10 to 90 days (average 21 days). Health Promotion
and Maintenance
123. B. Stage 2 is known as the birth or expulsion stage and is characterized by
complete dilation and effacement of the cervix until the birth of the baby.
Choices A, C, and D are incorrect. Health Promotion and Maintenance
124. C. Offering the client food that is factory- sealed will diminish the clients
anxiety and paranoia regarding the staff trying to poison her. Psychosocial
Integrity
125. C. Clients using the drug Thorazine should stay out of the sun secondary to
the risk of photosensitivity. Psychosocial Integrity
126. B. is correct. A, C, and D are incorrect choices. Psychosocial Integrity
127. D. It is customary in the Hindu faith that only family members touch
the body after death. The other statements are correct. Follow up is not
necessary. Psychosocial Integrity
128. C. Lannecs cirrhosis, common in alcoholics can lead to thiamine deciency.
Deciency of this vitamin can lead to alcoholic brain disease. Physiological
Integrity; Basic Care and Comfort
68
129. C. Barley, rye, oat and wheat (BROW) are foods to be avoided with Celiac
Disease. Corn (popcorn) and rice are allowed. Physiological Integrity; Basic
Care and Comfort
130. C. Clients with renal failure require decreased sodium in the diet. Corned
beef is high in sodium. Physiological Integrity; Basic Care and Comfort
131. B. is correct. Physiological Integrity; Basic Care and Comfort
132. B. Red foods should be avoided as they may be mistaken for blood.
133. Isometric is the correct term to describe this type of exercise.
134. B. When using the 3-point gait rst move both crutches and the weaker
limb forward. Then bear all your weight down through the crutches, and
then move the stronger or unaffected lower limb forward. This eliminates all
weight bearing on the affected leg. Physiological Integrity; Basic Care and
Comfort
135. 2.7 mg
Remember 2.2 lbs = 1 kg
6lbs 2.2 = 2.7 kg
2.7kg X 1MG = 2.7mg Physiological Integrity; Pharmacological and
136. 31 gtts/min
1000 ml X 15 gtt/ml = 31.25gtts/min
(8hrs X 60 minutes) Physiological Integrity; Pharmacological and Parenteral
Therapies
69
137. 19ml/hr
Formula: Desire X Volume X Weight X Min.
Have
Remember 2.2 lbs = 1 kg 185 lbs 2.2 = 84.09 kg
3mcg X 500ml X 84.09 kg X 60 minutes
400 mg
Convert 400 mg to mcg = 400,000 mcg
3mcg X 500ml X 84.09 kg X 60 minutes
400,000 mcg
Simplify division by dividing 500ml into 400,000mcg
3mcg X 5ml X 84.09 kg X 60 mins = 75,681
4,000 mcg
18.9ml Round to 19ml/hr Physiological Integrity; Pharmacological and
138. C. is correct. Humorsol is a cholinergic that is used when miotics are not
effective. A. Cyclogyl is a mydriatic. Timolol is a beta blocker used for ocular
hypertension. Physiological Integrity; Pharmacological and Parenteral
Therapies
139. B. Constipation is a common side effect of Clozaril. Choices A, C, and D are
incorrect. Hyperglycemia, an elevated white blood count and hypotension
are common. Physiological Integrity; Pharmacological and Parenteral
Therapies
140. A, E, and F are correct. Cardura may decrease libido. Choices C and D are
incorrect. Physiological Integrity; Pharmacological and Parenteral Therapies
70
141. D. is correct. Hyperactivity, anorexia, and weight loss are common adverse
reactions. Physiological Integrity; Pharmacological and Parenteral
Therapies
142. C. Questran is a lipid lowering agent. Physiological Integrity;
143. C. These symptoms are representative of hypocalcemia. Physiological
Integrity; Reduction of Risk Potential
144. B. Multiple Myeloma causes an interference with red blood cell, white blood
cell and platelet production. Physiological Integrity; Reduction of Risk
Potential
145. C . The glascow coma scale is the most widely used scale to quantify level
of consciousness following traumatic brain injury. The maximum score is 15
the minimal score is 3. Levels less than 8 indicate a coma. The following
scores should be given. Eye opening to speech (3), client obeys commands
(6), confused conversation (4) total 13. Physiological Integrity; Reduction
of Risk Potential
146. B, D, E, F. The client should be placed on the affected side. Coughing is
contraindicated after eye surgery. Physiological Integrity; Reduction of Risk
Potential
147. A, B, C, E. Insomnia and palpitations are common in a client with
hyperthyroidism. Physiological Integrity; Reduction of Risk Potential
148. A. A female with frequent yeast infections should be evaluated for Diabetes
Mellitus and HIV. Physiological Integrity; Reduction of Risk Potential
149. C. The nurse should assess the clients glucose level before proceeding to
the subsequent steps. Physiological Integrity; Physiological Adaptation
150. D. Although the PH is slightly low, and the PaCo2 is elevated this arterial
blood gas (ABG) is normal for a client with COPD as they cannot breathe
out. This client is the most stable and can be discharged. Choice A- may be
71
exhibiting symptoms of Autotomonic Dysreexia. Choice B- continuous or

excessive bubbling is indicative of an air leak. Choice C- a Lithium level of
1.8 indicates Lithium toxicity. Clients A, B, C should remain in the hospital.
72
Bonus Rationales
1. Following cardiac catheterization using the femoral artery the distal
peripheral pulses in the affected extremity are assessed. Since the femoral
artery was used, the pulses requiring assessment are the dorsalis pedis and
posterior tibial.
73
2. Fifth disease is characterized by erythema of the face which usually has a

(slapped face appearance) chiey on the cheeks. The rash disappears by
1-4 days. Next, the rash will appear on the extremities and progress from
proximal to distal surfaces for approximately one week.
74
3. The vastus lateralis is a large muscle and medications are well absorbed.
These injections are given on the lateral aspect of the thigh. This is the
preferred site for infants 7 months or younger. Because of underdevelopment
of the posterior gluteal muscle in a child who has been walking for less than a
year this site is avoided in children less than two years of age.
75
4. The P wave represents the electrical impulse starting in the sinus node
and spreading through the atria. The P wave represents atrial muscle
depolarization.
5. Correct placement for self-adhesive electrode pads is one pad on the upper
right sternal border directly below the clavicle. The second pad should be
placed lateral to the left nipple with the top margin of the pad a few inches
below the axillae.
76
6. The nurse should palpate the posterior superior iliac spine and draw an
imaginary line to the greater trochanter. The injection is superior and lateral
to this line. Caution should be used to avoid giving the injection posterior to
this imaginary line to avoid the sciatic nerve.
77
7. If a client is infected with TB, the chest x-ray will usually reveal inltrates in
the upper lobes of the lungs.
78
Important Contacts
National Council of State Boards of Nursing

111 East Wacker Drive
Suite 2900
Chicago, Il 60601
(312) 525-3600 (phone)
(312) 279-1032 (fax)
(866) 293-9600 toll-free testing number
Locate your local State board of Nursing at:www.ncsbn.org
Ofce of the Professions
State Board for Nursing
State Education Building 2nd Floor
Albany, NY 12234
(518) 474-3817 ext. 120 (phone)
(518) 474-3707 (fax)
www.op.nysed.gov
Testing Centers
Pearson Vue
United States
(866) 496-2539
Schedule your test at a location near you.
www.vue.com/nclex
79
80
About the Authors

Rhonda Gumbs-Savain RN, BSN, MSN, Certied Teacher- Has been a nurse for 21
years who was inspired to write the book after having contact with many students
who needed assistance with analysis and critical thinking. She has been a nursing
educator for 13 years. Her professional background includes experience as a
Hospital Corpsman in the United States Naval Reserves, faculty lecturer for LPN
students and Assistant Professor of Nursing for RN students.
Derrice Jordan RN, BSN, MSN, FNP- A nursing professional for 23 years she has
provided the arena for furthering educational skills and mastery of nursing. A
proven leader, her professional background includes experience as an Assistant
Nurse Manager, mentor to students, Adjunct Lecturer and clinical instructor. She is
also licensed as a Family Nurse Practitioner.

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Nclex-Rn Essential Questions and Rationales

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101 Essential Questions

for the RN-to-Be!

2008 Rhonda Gumbs-Savain and Derrice Jordan. All Rights Reserved.

Contributors and Consultants

Patricia A. Mahoney, MSN, RN

Diana J. Mosley, MA, MEd., RN

Tracy A. Ortelli, MS, RN

An inspirational reminder of why Nurses are special

B. Safety and Infection Control- Protecting clients and health care

III. Psychosocial Integrity Providing and directing nursing care that

IV. Physiological Integrity

Alternative and Complimentary Therapies*

B. Pharmacological and Parenteral Therapies - Managing and providing

Central Venous Access Devices

C. Reduction of Risk Potential - Reducing the likelihood that clients will

Alterations in Body Systems

Unexpected Response to Therapies

There is an on screen calculator available to calculate medication dosages.

Once a question is answered you will not be allowed to change it.

NCLEX is a computer adaptive test which means it adjusts based on the

6 hours are allotted for the RN exam to complete a minimum of 75 to a

Test Taking Techniques

Determine what the question is asking.

Priority, rst - indicate that you need to determine the most

Anticipate, most appropriate, correct, expected, should, include,

Intervene, require follow-up, needs additional teaching, require

Rhonda Gumbs-Savain and Derrice Jordan

you are looking for an incorrect or unexpected response

101 Essential Questions for the RN-to-Be!

The nursing process; caring; communication; documentation; teaching and

And the Journey Continues

Are You Ready To Pass?

Rhonda Gumbs-Savain and Derrice Jordan

1. The nurse is reviewing medical prescriptions for newly admitted clients. It

101 Essential Questions for the RN-to-Be!

Rhonda Gumbs-Savain and Derrice Jordan

8. It would be appropriate to assign which of these tasks to the CNA?

101 Essential Questions for the RN-to-Be!

Rhonda Gumbs-Savain and Derrice Jordan

101 Essential Questions for the RN-to-Be!

Rhonda Gumbs-Savain and Derrice Jordan

101 Essential Questions for the RN-to-Be!

Rhonda Gumbs-Savain and Derrice Jordan

101 Essential Questions for the RN-to-Be!

Rhonda Gumbs-Savain and Derrice Jordan

101 Essential Questions for the RN-to-Be!

42. The nurse has attended a staff development conference on cultural

Rhonda Gumbs-Savain and Derrice Jordan

101 Essential Questions for the RN-to-Be!

Rhonda Gumbs-Savain and Derrice Jordan

101 Essential Questions for the RN-to-Be!

Rhonda Gumbs-Savain and Derrice Jordan

101 Essential Questions for the RN-to-Be!

Rhonda Gumbs-Savain and Derrice Jordan

101 Essential Questions for the RN-to-Be!

Rhonda Gumbs-Savain and Derrice Jordan

101 Essential Questions for the RN-to-Be!

Rhonda Gumbs-Savain and Derrice Jordan

101 Essential Questions for the RN-to-Be!

Rhonda Gumbs-Savain and Derrice Jordan

101 Essential Questions for the RN-to-Be!

Rhonda Gumbs-Savain and Derrice Jordan

101 Essential Questions for the RN-to-Be!