PNLE III for Care of Clients with Physiologic and
Psychosocial Alterations (Part 1)
1. Nurse Michelle should know that the drainage is normal
4 days after a sigmoid colostomy when the stool is:
A. Green liquid
B. Solid formed
C. Loose, bloody
D. Semiformed
2. Where would nurse Kristine place the call light for a
male client with a right-sided brain attack and left
homonymous hemianopsia?
A. On the client’s right side
B. On the client’s left side
C. Directly in front of the client
D. Where the client like
3. A male client is admitted to the emergency department
following an accident. What are the first nursing actions of
the nurse?
A. Check respiration, circulation, neurological response.
B. Align the spine, check pupils, and check for
hemorrhage.
C. Check respirations, stabilize spine, and check
circulation.
D. Assess level of consciousness and circulation.
4. In evaluating the effect of nitroglycerin, Nurse Arthur
should know that it reduces preload and relieves angina
by:
A. Increasing contractility and slowing heart rate.
B. Increasing AV conduction and heart rate.
C. Decreasing contractility and oxygen consumption.
D. Decreasing venous return through vasodilation.
5. Nurse Patricia finds a female client who is post-
myocardial infarction (MI) slumped on the side rails of the
bed and unresponsive to shaking or shouting. Which is the
nurse next action?
A. Call for help and note the time.
B. Clear the airway
C. Give two sharp thumps to the precordium, and check
the pulse.
D. Administer two quick blows.
6. Nurse Monett is caring for a client recovering from
gastro-intestinal bleeding. The nurse should:
A. Plan care so the client can receive 8 hours of
uninterrupted sleep each night.
B. Monitor vital signs every 2 hours.
C. Make sure that the client takes food and medications
at prescribed intervals.
D. Provide milk every 2 to 3 hours.
7. A male client was on warfarin (Coumadin) before
admission, and has been receiving heparin I.V. for 2 days.
The partial thromboplastin time (PTT) is 68 seconds. What
should Nurse Carla do?
A. Stop the I.V. infusion of heparin and notify the
physician.
B. Continue treatment as ordered.
C. Expect the warfarin to increase the PTT.
D. Increase the dosage, because the level is lower than
normal.
8. A client undergone ileostomy, when should the drainage
appliance be applied to the stoma?
A. 24 hours later, when edema has subsided.
B. In the operating room.
C. After the ileostomy begin to function.
D. When the client is able to begin self-care procedures.
9. A client undergone spinal anesthetic, it will be important
that the nurse immediately position the client in:
A. On the side, to prevent obstruction of airway by
tongue.
B. Flat on back.
C. On the back, with knees flexed 15 degrees.
D. Flat on the stomach, with the head turned to the side.
10.While monitoring a male client several hours after a
motor vehicle accident, which assessment data suggest
increasing intracranial pressure?
A. Blood pressure is decreased from 160/90 to 110/70.
B. Pulse is increased from 87 to 95, with an occasional
skipped beat.
C. The client is oriented when aroused from sleep, and
goes back to sleep immediately.
D. The client refuses dinner because of anorexia.
11.Mrs. Cruz, 80 years old is diagnosed with pneumonia.
Which of the following symptoms may appear first?
A. Altered mental status and dehydration
B. Fever and chills
C. Hemoptysis and Dyspnea
D. Pleuritic chest pain and cough
12. A male client has active tuberculosis (TB). Which of the
following symptoms will be exhibit?
A. Chest and lower back pain
B. Chills, fever, night sweats, and hemoptysis
C. Fever of more than 104°F (40°C) and nausea
D. Headache and photophobia
13. Mark, a 7-year-old client is brought to the emergency D. Removing the hair with a depilatory.
department. He’s tachypneic and afebrile and has a
respiratory rate of 36 breaths/minute and has a 19. Nurse Michelle is caring for an elderly female with
nonproductive cough. He recently had a cold. Form this osteoporosis. When teaching the client, the nurse should
history; the client may have which of the following include information about which major complication:
conditions?
A. Bone fracture
A. Acute asthma B. Loss of estrogen
B. Bronchial pneumonia C. Negative calcium balance
C. Chronic obstructive pulmonary disease (COPD) D. Dowager’s hump
D. Emphysema
20. Nurse Len is teaching a group of women to perform
14. Marichu was given morphine sulfate for pain. She is BSE. The nurse should explain that the purpose of
sleeping and her respiratory rate is 4 breaths/minute. If performing the examination is to discover:
action isn’t taken quickly, she might have which of the
following reactions? A. Cancerous lumps
B. Areas of thickness or fullness
A. Asthma attack C. Changes from previous examinations.
B. Respiratory arrest D. Fibrocystic masses
C. Seizure
D. Wake up on his own 21. When caring for a female client who is being treated for
hyperthyroidism, it is important to:
15. A 77-year-old male client is admitted for elective knee
surgery. Physical examination reveals shallow respirations A. Provide extra blankets and clothing to keep the client
but no sign of respiratory distress. Which of the following warm.
is a normal physiologic change related to aging? B. Monitor the client for signs of restlessness, sweating,
and excessive weight loss during thyroid
A. Increased elastic recoil of the lungs replacement therapy.
B. Increased number of functional capillaries in the C. Balance the client’s periods of activity and rest.
alveoli D. Encourage the client to be active to prevent
C. Decreased residual volume constipation.
D. Decreased vital capacity
22. Nurse Kris is teaching a client with history of
16. Nurse John is caring for a male client receiving atherosclerosis. To decrease the risk of atherosclerosis, the
lidocaine I.V. Which factor is the most relevant to nurse should encourage the client to:
administration of this medication?
A. Avoid focusing on his weight.
A. Decrease in arterial oxygen saturation (SaO2) when B. Increase his activity level.
measured with a pulse oximeter. C. Follow a regular diet.
B. Increase in systemic blood pressure. D. Continue leading a high-stress lifestyle.
C. Presence of premature ventricular contractions
(PVCs) on a cardiac monitor. 23. Nurse Greta is working on a surgical floor. Nurse Greta
D. Increase in intracranial pressure (ICP). must logroll a client following a:

17. Nurse Ron is caring for a male client taking an A. Laminectomy

anticoagulant. The nurse should teach the client to: B. Thoracotomy
C. Hemorrhoidectomy
A. Report incidents of diarrhea. D. Cystectomy.
B. Avoid foods high in vitamin K
C. Use a straight razor when shaving. 24. A 55-year old client underwent cataract removal with
D. Take aspirin to pain relief. intraocular lens implant. Nurse Oliver is giving the client
discharge instructions. These instructions should include
18. Nurse Lhynnette is preparing a site for the insertion of which of the following?
an I.V. catheter. The nurse should treat excess hair at the
site by: A. Avoid lifting objects weighing more than 5 lb (2.25
kg).
A. Leaving the hair intact B. Lie on your abdomen when in bed
B. Shaving the area C. Keep rooms brightly lit.
C. Clipping the hair in the area
 D. Avoiding straining during bowel movement or C. Place the client o his back, remove dangerous objects,
bending at the waist. and hold down his arms.
D. Place the client on his side, remove dangerous
25. George should be taught about testicular examinations objects, and protect his head.
during:
31. After insertion of a cheat tube for a pneumothorax, a
A. when sexual activity starts client becomes hypotensive with neck vein distention,
B. After age 69 tracheal shift, absent breath sounds, and diaphoresis.
C. After age 40 Nurse Amanda suspects a tension pneumothorax has
D. Before age 20. occurred. What cause of tension pneumothorax should the
nurse check for?
26. A male client undergone a colon resection. While
turning him, wound dehiscence with evisceration occurs. A. Infection of the lung.
Nurse Trish first response is to: B. Kinked or obstructed chest tube
C. Excessive water in the water-seal chamber
A. Call the physician D. Excessive chest tube drainage
B. Place a saline-soaked sterile dressing on the wound.
C. Take a blood pressure and pulse. 32. Nurse Maureen is talking to a male client, the client
D. Pull the dehiscence closed. begins choking on his lunch. He’s coughing forcefully. The
nurse should:
27. Nurse Audrey is caring for a client who has suffered a
severe cerebrovascular accident. During routine A. Stand him up and perform the abdominal thrust
assessment, the nurse notices Cheyne- Strokes maneuver from behind.
respirations. Cheyne-strokes respirations are: B. Lay him down, straddle him, and perform the
abdominal thrust maneuver.
A. A progressively deeper breaths followed by C. Leave him to get assistance
shallower breaths with apneic periods. D. Stay with him but not intervene at this time.
B. Rapid, deep breathing with abrupt pauses between
each breath. 33. Nurse Ron is taking a health history of an 84 year old
C. Rapid, deep breathing and irregular breathing client. Which information will be most useful to the nurse
without pauses. for planning care?
D. Shallow breathing with an increased respiratory rate.
A. General health for the last 10 years.
28. Nurse Bea is assessing a male client with heart failure. B. Current health promotion activities.
The breath sounds commonly auscultated in clients with C. Family history of diseases.
heart failure are: D. Marital status.

A. Tracheal 34. When performing oral care on a comatose client, Nurse

B. Fine crackles Krina should:
C. Coarse crackles
D. Friction rubs A. Apply lemon glycerin to the client’s lips at least every
2 hours.
29. The nurse is caring for Kenneth experiencing an acute B. Brush the teeth with client lying supine.
asthma attack. The client stops wheezing and breath C. Place the client in a side lying position, with the head
sounds aren’t audible. The reason for this change is that: of the bed lowered.
D. Clean the client’s mouth with hydrogen peroxide.
A. The attack is over.
B. The airways are so swollen that no air cannot get 35. A 77-year-old male client is admitted with a diagnosis
through. of dehydration and change in mental status. He’s being
C. The swelling has decreased. hydrated with L.V. fluids. When the nurse takes his vital
D. Crackles have replaced wheezes. signs, she notes he has a fever of 103°F (39.4°C) a
cough producing yellow sputum and pleuritic chest pain.
30. Mike with epilepsy is having a seizure. During the The nurse suspects this client may have which of the
active seizure phase, the nurse should: following conditions?

A. Place the client on his back remove dangerous A. Adult respiratory distress syndrome (ARDS)
objects, and insert a bite block. B. Myocardial infarction (MI)
B. Place the client on his side, remove dangerous C. Pneumonia
objects, and insert a bite block. D. Tuberculosis
36. Nurse Oliver is working in a out patient clinic. He has
been alerted that there is an outbreak of tuberculosis (TB).
Which of the following clients entering the clinic today
most likely to have TB?
A. A 16-year-old female high school student
B. A 33-year-old day-care worker
C. A 43-yesr-old homeless man with a history of
alcoholism
D. A 54-year-old businessman
37. Virgie with a positive Mantoux test result will be sent
for a chest X-ray. The nurse is aware that which of the
following reasons this is done?
A. To confirm the diagnosis
B. To determine if a repeat skin test is needed
C. To determine the extent of lesions
D. To determine if this is a primary or secondary
infection
38. Kennedy with acute asthma showing inspiratory and
expiratory wheezes and a decreased forced expiratory
volume should be treated with which of the following
classes of medication right away?
A. Beta-adrenergic blockers
B. Bronchodilators
C. Inhaled steroids
D. Oral steroids
39. Mr. Vasquez 56-year-old client with a 40-year history
of smoking one to two packs of cigarettes per day has a
chronic cough producing thick sputum, peripheral edema
and cyanotic nail beds. Based on this information, he
most likely has which of the following conditions?
A. Adult respiratory distress syndrome (ARDS)
B. Asthma
C. Chronic obstructive bronchitis
D. Emphysema
Situation: Francis, age 46 is admitted to the hospital with
diagnosis of Chronic Lymphocytic Leukemia.
40. The treatment for patients with leukemia is bone
marrow transplantation. Which statement about bone
marrow transplantation is not correct?
A. The patient is under local anesthesia during the
procedure
B. The aspirated bone marrow is mixed with heparin.
C. The aspiration site is the posterior or anterior iliac
crest.
D. The recipient receives cyclophosphamide (Cytoxan)
for 4 consecutive days before the procedure.
41. After several days of admission, Francis becomes
disoriented and complains of frequent headaches. The
nurse in-charge first action would be:
A. Call the physician
B. Document the patient’s status in his charts.
C. Prepare oxygen treatment
D. Raise the side rails
42. During routine care, Francis asks the nurse, “How can I
be anemic if this disease causes increased my white blood
cell production?” The nurse in-charge best response would
be that the increased number of white blood cells (WBC)
is:
A. Crowd red blood cells
B. Are not responsible for the anemia.
C. Uses nutrients from other cells
D. Have an abnormally short life span of cells.
43. Diagnostic assessment of Francis would probably not
reveal:
A. Predominance of lymhoblasts
B. Leukocytosis
C. Abnormal blast cells in the bone marrow
D. Elevated thrombocyte counts
44. Robert, a 57-year-old client with acute arterial
occlusion of the left leg undergoes an emergency
embolectomy. Six hours later, the nurse isn’t able to obtain
pulses in his left foot using Doppler ultrasound. The nurse
immediately notifies the physician, and asks her to prepare
the client for surgery. As the nurse enters the client’s room
to prepare him, he states that he won’t have any
more surgery. Which of the following is the best initial
response by the nurse?
A. Explain the risks of not having the surgery
B. Notifying the physician immediately
C. Notifying the nursing supervisor
D. Recording the client’s refusal in the nurses’ notes
45. During the endorsement, which of the following clients
should the on-duty nurse assess first?
A. The 58-year-old client who was admitted 2 days ago
with heart failure, blood pressure of 126/76 mm Hg,
and a respiratory rate of 22 breaths/minute.
B. The 89-year-old client with end-stage right-sided
heart failure, blood pressure of 78/50 mm Hg, and a
“do not resuscitate” order
C. The 62-year-old client who was admitted 1 day ago
with thrombophlebitis and is receiving L.V. heparin
D. The 75-year-old client who was admitted 1 hour ago
with new-onset atrial fibrillation and is receiving L.V.
dilitiazem (Cardizem)
46. Honey, a 23-year old client complains of substernal
chest pain and states that her heart feels like “it’s racing
out of the chest”. She reports no history of cardiac
disorders. The nurse attaches her to a cardiac monitor and
notes sinus tachycardia with a rate of 136beats/minutes.
Breath sounds are clear and the respiratory rate is 26
breaths/minutes. Which of the following drugs should
the nurse question the client about using?
A. Barbiturates
B. Opioids
C. Cocaine
D. Benzodiazepines
47. A 51-year-old female client tells the nurse in-charge
that she has found a painless lump in her right breast
during her monthly self-examination. Which assessment
finding would strongly suggest that this client’s lump is
cancerous?
A. Eversion of the right nipple and mobile mass
B. Nonmobile mass with irregular edges
C. Mobile mass that is soft and easily delineated
D. Nonpalpable right axillary lymph nodes
48. A 35-year-old client with vaginal cancer asks the nurse,
“What is the usual treatment for this type of cancer?”
Which treatment should the nurse name?
A. Surgery
B. Chemotherapy
C. Radiation
D. Immunotherapy
49. Cristina undergoes a biopsy of a suspicious lesion. The
biopsy report classifies the lesion according to the TNM
staging system as follows: TIS, N0, M0. What does this
classification mean?
A. No evidence of primary tumor, no abnormal regional
lymph nodes, and no evidence of distant metastasis
B. Carcinoma in situ, no abnormal regional lymph
nodes, and no evidence of distant metastasis
C. Can’t assess tumor or regional lymph nodes and no
evidence of metastasis
D. Carcinoma in situ, no demonstrable metastasis of the
regional lymph nodes, and ascending degrees of
distant metastasis
50. Lydia undergoes a laryngectomy to treat laryngeal
cancer. When teaching the client how to care for the neck
stoma, the nurse should include which instruction?
A. “Keep the stoma uncovered.”
B. “Keep the stoma dry.”
C. “Have a family member perform stoma care initially
until you get used to the procedure.”
D. “Keep the stoma moist.”
51. A 37-year-old client with uterine cancer asks the nurse,
“Which is the most common type of cancer in women?”
The nurse replies that it’s breast cancer. Which type of
cancer causes the most deaths in women?
A. Breast cancer
B. Lung cancer
C. Brain cancer
D. Colon and rectal cancer
52. Antonio with lung cancer develops Horner’s syndrome
when the tumor invades the ribs and affects the
sympathetic nerve ganglia. When assessing for signs and
symptoms of this syndrome, the nurse should note:
A. miosis, partial eyelid ptosis, and anhidrosis on the
affected side of the face.
B. chest pain, dyspnea, cough, weight loss, and fever.
C. arm and shoulder pain and atrophy of arm and hand
muscles, both on the affected side.
D. hoarseness and dysphagia.
53. Vic asks the nurse what PSA is. The nurse should reply
that it stands for:
A. prostate-specific antigen, which is used to screen for
prostate cancer.
B. protein serum antigen, which is used to determine
protein levels.
C. pneumococcal strep antigen, which is a bacteria that
causes pneumonia.
D. Papanicolaou-specific antigen, which is used to
screen for cervical cancer.
54. What is the most important postoperative instruction
that nurse Kate must give a client who has just returned
from the operating room after receiving a subarachnoid
block?
A. “Avoid drinking liquids until the gag reflex returns.”
B. “Avoid eating milk products for 24 hours.”
C. “Notify a nurse if you experience blood in your urine.”
D. “Remain supine for the time specified by the
physician.”
55. A male client suspected of having colorectal cancer will
require which diagnostic study to confirm the diagnosis?
A. Stool Hematest
B. Carcinoembryonic antigen (CEA)
C. Sigmoidoscopy
D. Abdominal computed tomography (CT) scan
56. During a breast examination, which finding most
strongly suggests that the Luz has breast cancer?
A. Slight asymmetry of the breasts.
B. A fixed nodular mass with dimpling of the overlying
skin
 C. Bloody discharge from the nipple
D. Multiple firm, round, freely movable masses that
change with the menstrual cycle
57. A female client with cancer is being evaluated for
possible metastasis. Which of the following is one of the
most common metastasis sites for cancer cells?
A. Liver
B. Colon
C. Reproductive tract
D. White blood cells (WBCs)
58. Nurse Mandy is preparing a client for magnetic
resonance imaging (MRI) to confirm or rule out a spinal
cord lesion. During the MRI scan, which of the following
would pose a threat to the client?
A. The client lies still.
B. The client asks questions.
C. The client hears thumping sounds.
D. The client wears a watch and wedding band.
59. Nurse Cecile is teaching a female client about
preventing osteoporosis. Which of the following teaching
points is correct?
A. Obtaining an X-ray of the bones every 3 years is
recommended to detect bone loss.
B. To avoid fractures, the client should avoid strenuous
exercise.
C. The recommended daily allowance of calcium may be
found in a wide variety of foods.
D. Obtaining the recommended daily allowance of
calcium requires taking a calcium supplement.
60. Before Jacob undergoes arthroscopy, the nurse reviews
the assessment findings for contraindications for this
procedure. Which finding is a contraindication?
A. Joint pain
B. Joint deformity
C. Joint flexion of less than 50%
D. Joint stiffness
61. Mr. Rodriguez is admitted with severe pain in the
knees. Which form of arthritis is characterized by urate
deposits and joint pain, usually in the feet and legs, and
occurs primarily in men over age 30?
A. Septic arthritis
B. Traumatic arthritis
C. Intermittent arthritis
D. Gouty arthritis
62. A heparin infusion at 1,500 unit/hour is ordered for a
64-year-old client with stroke in evolution. The infusion
contains 25,000 units of heparin in 500 ml of saline
solution. How many milliliters per hour should be given?
A. 15 ml/hour
B. 30 ml/hour
C. 45 ml/hour
D. 50 ml/hour
63. A 76-year-old male client had a thromboembolic right
stroke; his left arm is swollen. Which of the following
conditions may cause swelling after a stroke?
A. Elbow contracture secondary to spasticity
B. Loss of muscle contraction decreasing venous return
C. Deep vein thrombosis (DVT) due to immobility of the
ipsilateral side
D. Hypoalbuminemia due to protein escaping from an
inflamed glomerulus
64. Heberden’s nodes are a common sign of osteoarthritis.
Which of the following statement is correct about this
deformity?
A. It appears only in men
B. It appears on the distal interphalangeal joint
C. It appears on the proximal interphalangeal joint
D. It appears on the dorsolateral aspect of the
interphalangeal joint.
65. Which of the following statements explains the main
difference between rheumatoid arthritis and
osteoarthritis?
A. Osteoarthritis is gender-specific, rheumatoid arthritis
isn’t
B. Osteoarthritis is a localized disease rheumatoid
arthritis is systemic
C. Osteoarthritis is a systemic disease, rheumatoid
arthritis is localized
D. Osteoarthritis has dislocations and subluxations,
rheumatoid arthritis doesn’t
66. Mrs. Cruz uses a cane for assistance in walking. Which
of the following statements is true about a cane or other
assistive devices?
A. A walker is a better choice than a cane.
B. The cane should be used on the affected side
C. The cane should be used on the unaffected side
D. A client with osteoarthritis should be encouraged to
ambulate without the cane
67. A male client with type 1 diabetes is scheduled to
receive 30 U of 70/30 insulin. There is no 70/30 insulin
available. As a substitution, the nurse may give the client:
A. 9 U regular insulin and 21 U neutral protamine
Hagedorn (NPH).
B. 21 U regular insulin and 9 U NPH.
C. 10 U regular insulin and 20 U NPH.
D. 20 U regular insulin and 10 U NPH.
68. Nurse Len should expect to administer which C. serum fructosamine level.
medication to a client with gout? D. glycosylated hemoglobin level.

A. aspirin 74. Nurse Trinity administered neutral protamine

B. furosemide (Lasix) Hagedorn (NPH) insulin to a diabetic client at 7 a.m. At
C. colchicines what time would the nurse expect the client to be most at
D. calcium gluconate (Kalcinate) risk for a hypoglycemic reaction?

69. Mr. Domingo with a history of hypertension is A. 10:00 am

diagnosed with primary hyperaldosteronism. This B. Noon
diagnosis indicates that the client’s hypertension is caused C. 4:00 pm
by excessive hormone secretion from which of the D. 10:00 pm
following glands?
75. The adrenal cortex is responsible for producing which
A. Adrenal cortex substances?
B. Pancreas
C. Adrenal medulla A. Glucocorticoids and androgens
D. Parathyroid B. Catecholamines and epinephrine
C. Mineralocorticoids and catecholamines
70. For a diabetic male client with a foot ulcer, the doctor D. Norepinephrine and epinephrine
orders bed rest, a wetto- dry dressing change every shift,
and blood glucose monitoring before meals and bedtime. 76. On the third day after a partial thyroidectomy,
Why are wet-to-dry dressings used for this client? Proserfina exhibits muscle twitching and hyperirritability
of the nervous system. When questioned, the client reports
A. They contain exudate and provide a moist wound numbness and tingling of the mouth and fingertips.
environment. Suspecting a lifethreatening electrolyte disturbance, the
B. They protect the wound from mechanical trauma and nurse notifies the surgeon immediately. Which electrolyte
promote healing. disturbance most commonly follows thyroid surgery?
C. They debride the wound and promote healing by
secondary intention. A. Hypocalcemia
D. They prevent the entrance of microorganisms and B. Hyponatremia
minimize wound discomfort. C. Hyperkalemia
D. Hypermagnesemia
71. Nurse Zeny is caring for a client in acute addisonian
crisis. Which laboratory data would the nurse expect to 77. Which laboratory test value is elevated in clients who
find? smoke and can’t be used as a general indicator of cancer?

A. Hyperkalemia A. Acid phosphatase level

B. Reduced blood urea nitrogen (BUN) B. Serum calcitonin level
C. Hypernatremia C. Alkaline phosphatase level
D. Hyperglycemia D. Carcinoembryonic antigen level

72. A client is admitted for treatment of the syndrome of 78. Francis with anemia has been admitted to the medical-
inappropriate antidiuretic hormone (SIADH). Which surgical unit. Which assessment findings are characteristic
nursing intervention is appropriate? of iron-deficiency anemia?

A. Infusing I.V. fluids rapidly as ordered A. Nights sweats, weight loss, and diarrhea
B. Encouraging increased oral intake B. Dyspnea, tachycardia, and pallor
C. Restricting fluids C. Nausea, vomiting, and anorexia
D. Administering glucose-containing I.V. fluids as D. Itching, rash, and jaundice
ordered
79. In teaching a female client who is HIV-positive about
73. A female client tells nurse Nikki that she has been pregnancy, the nurse would know more teaching is
working hard for the last 3 months to control her type 2 necessary when the client says:
diabetes mellitus with diet and exercise. To determine the
effectiveness of the client’s efforts, the nurse should check: A. The baby can get the virus from my placenta.”
B. “I’m planning on starting on birth control pills.”
A. urine glucose level. C. “Not everyone who has the virus gives birth to a baby
B. fasting blood glucose level. who has the virus.”
 D. “I’ll need to have a C-section if I become pregnant and A. Neutrophil
have a baby.” B. Basophil
C. Monocyte
80. When preparing Judy with acquired immunodeficiency D. Lymphocyte
syndrome (AIDS) for discharge to the home, the nurse
should be sure to include which instruction? 85. In an individual with Sjögren’s syndrome, nursing care
should focus on:
A. “Put on disposable gloves before bathing.”
B. “Sterilize all plates and utensils in boiling water.” A. moisture replacement.
C. “Avoid sharing such articles as toothbrushes and B. electrolyte balance.
razors.” C. nutritional supplementation.
D. “Avoid eating foods from serving dishes shared by D. arrhythmia management.
other family members.”
86. During chemotherapy for lymphocytic leukemia,
81. Nurse Marie is caring for a 32-year-old client admitted Mathew develops abdominal pain, fever, and “horse barn”
with pernicious anemia. Which set of findings should the smelling diarrhea. It would be most important for
nurse expect when assessing the the nurse to advise the physician to order:

client? A. enzyme-linked immunosuppressant assay (ELISA)

A. Pallor, bradycardia, and reduced pulse pressure
B. Pallor, tachycardia, and a sore tongue
C. Sore tongue, dyspnea, and weight gain
D. Angina, double vision, and anorexia
82. After receiving a dose of penicillin, a client develops
dyspnea and hypotension. Nurse Celestina suspects the
client is experiencing anaphylactic shock. What should the
nurse do first?
test.
B. electrolyte panel and hemogram.
C. stool for Clostridium difficile test.
D. flat plate X-ray of the abdomen.
87. A male client seeks medical evaluation for fatigue, night
sweats, and a 20-lb weight loss in 6 weeks. To confirm that
the client has been infected with the human
immunodeficiency virus (HIV), the nurse expects the
physician to order:

A. Page an anesthesiologist immediately and prepare to A. E-rosette immunofluorescence.

intubate the client. B. quantification of T-lymphocytes.
B. Administer epinephrine, as prescribed, and prepare C. enzyme-linked immunosorbent assay (ELISA).
to intubate the client if necessary. D. Western blot test with ELISA.
C. Administer the antidote for penicillin, as prescribed,
and continue to monitor the client’s vital signs. 88. A complete blood count is commonly performed before
D. Insert an indwelling urinary catheter and begin to a Joe goes into surgery. What does this test seek to
infuse I.V. fluids as ordered. identify?

83. Mr. Marquez with rheumatoid arthritis is about to
begin aspirin therapy to reduce inflammation. When
teaching the client about aspirin, the nurse discusses
adverse reactions to prolonged aspirin therapy. These
include:
A. weight gain.
B. fine motor tremors.
C. respiratory acidosis.
D. bilateral hearing loss.
84. A 23-year-old client is diagnosed with human
immunodeficiency virus (HIV). After recovering from the
initial shock of the diagnosis, the client expresses a desire
to learn as much as possible about HIV and acquired
immunodeficiency syndrome (AIDS). When teaching the
client about the immune system, the nurse states that
adaptive immunity is provided by which type of white
blood cell?
A. Potential hepatic dysfunction indicated by decreased
blood urea nitrogen (BUN) and creatinine levels
B. Low levels of urine constituents normally excreted in
the urine
C. Abnormally low hematocrit (HCT) and hemoglobin
(Hb) levels
D. Electrolyte imbalance that could affect the blood’s
ability to coagulate properly
89. While monitoring a client for the development of
disseminated intravascular coagulation (DIC), the nurse
should take note of what assessment parameters?
A. Platelet count, prothrombin time, and partial
thromboplastin time
B. Platelet count, blood glucose levels, and white blood
cell (WBC) count
C. Thrombin time, calcium levels, and potassium levels
D. Fibrinogen level, WBC, and platelet count
90. When taking a dietary history from a newly admitted
female client, Nurse Len should remember that which of
the following foods is a common allergen?
A. Bread
B. Carrots
C. Orange
D. Strawberries
91. Nurse John is caring for clients in the outpatient clinic.
Which of the following phone calls should the nurse return
first?
A. A client with hepatitis A who states, “My arms and
legs are itching.”
B. A client with cast on the right leg who states, “I have a
funny feeling in my right leg.”
C. A client with osteomyelitis of the spine who states, “I
am so nauseous that I can’t eat.”
D. A client with rheumatoid arthritis who states, “I am
having trouble sleeping.”
92. Nurse Sarah is caring for clients on the surgical floor
and has just received report from the previous shift. Which
of the following clients should the nurse see first?
A. A 35-year-old admitted three hours ago with a
gunshot wound; 1.5 cm area of dark drainage noted
on the dressing.
B. A 43-year-old who had a mastectomy two days ago;
23 ml of serosanguinous fluid noted in the Jackson-
Pratt drain.
C. A 59-year-old with a collapsed lung due to an
accident; no drainage noted in the previous eight
hours.
D. A 62-year-old who had an abdominal-perineal
resection three days ago; client complaints of chills.
93. Nurse Eve is caring for a client who had a
thyroidectomy 12 hours ago for treatment of Grave’s
disease. The nurse would be most concerned if which of
the following was observed?
A. Blood pressure 138/82, respirations 16, oral
temperature 99 degrees Fahrenheit.
B. The client supports his head and neck when turning
his head to the right.
C. The client spontaneously flexes his wrist when the
blood pressure is obtained.
D. The client is drowsy and complains of sore throat.
94. Julius is admitted with complaints of severe pain in the
lower right quadrant of the abdomen. To assist with pain
relief, the nurse should take which of the following
actions?
A. Encourage the client to change positions frequently
in bed.
B. Administer Demerol 50 mg IM q 4 hours and PRN.
C. Apply warmth to the abdomen with a heating pad.
D. Use comfort measures and pillows to position the
client.
95. Nurse Tina prepares a client for peritoneal dialysis.
Which of the following actions should the nurse take first?
A. Assess for a bruit and a thrill.
B. Warm the dialysate solution.
C. Position the client on the left side.
D. Insert a Foley catheter
96. Nurse Jannah teaches an elderly client with right-sided
weakness how to use cane. Which of the following
behaviors, if demonstrated by the client to the
nurse, indicates that the teaching was effective?
A. The client holds the cane with his right hand, moves
the can forward followed by the right leg, and then
moves the left leg.
B. The client holds the cane with his right hand, moves
the cane forward followed by his left leg, and then
moves the right leg.
C. The client holds the cane with his left hand, moves
the cane forward followed by the right leg, and then
moves the left leg.
D. The client holds the cane with his left hand, moves
the cane forward followed by his left leg, and then
moves the right leg.
97. An elderly client is admitted to the nursing home
setting. The client is occasionally confused and her gait is
often unsteady. Which of the following actions, if taken by
the nurse, is most appropriate?
A. Ask the woman’s family to provide personal items
such as photos or mementos.
B. Select a room with a bed by the door so the woman
can look down the hall.
C. Suggest the woman eat her meals in the room with
her roommate.
D. Encourage the woman to ambulate in the halls twice
a day.
98. Nurse Evangeline teaches an elderly client how to use a
standard aluminum walker. Which of the following
behaviors, if demonstrated by the client, indicates that the
nurse’s teaching was effective?
A. The client slowly pushes the walker forward 12
inches, then takes small steps forward while leaning
on the walker.
B. The client lifts the walker, moves it forward 10
inches, and then takes several small steps forward.
C. The client supports his weight on the walker while
advancing it forward, then takes small steps while
balancing on the walker.
 D. The client slides the walker 18 inches forward, then
takes small steps while holding onto the walker for
balance.

99. Nurse Deric is supervising a group of elderly clients in

a residential home setting. The nurse knows that the
elderly are at greater risk of developing sensory
deprivation for what reason?

A. Increased sensitivity to the side effects of

medications.
B. Decreased visual, auditory, and gustatory abilities.
C. Isolation from their families and familiar
surroundings.
D. Decrease musculoskeletal function and mobility.

100. A male client with emphysema becomes restless and

confused. What step should nurse Jasmine take next?

A. Encourage the client to perform pursed lip breathing.

B. Check the client’s temperature.
C. Assess the client’s potassium level.
D. Increase the client’s oxygen flow rate.