1.
A nurse is preparing to care for a client with a potassium
deficit. The nurse reviews the client's record and
determines that the client was at risk for developing the
potassium deficit because the client:
a. has renal failure
b. requires nasogastric suction
c. has a history of Addison's disease
d. is taking a potassium-sparing diuretic
2. A client with a history of abusing barbiturates abruptly
stops taking the medication. The nurse should give priority
to assessing the client for:
a. Depression and suicidal ideation
b. Tachycardia and diarrhea
c. Muscle cramping and abdominal pain
d. Tachycardia and euphoric mood
3. A nurse reviews the blood gas results of client with
Guillain-Barre syndrome. The nurse analyzes the results
and determines that the client is experiencing respiratory
acidosis. Which of the following validates the nurse's
findings?
a. pH 7.25, Pco2 50 mm Hg
b. pH 7.35, Pco2 40 mm Hg
c. pH 7.50, Pco2 52 mm Hg
d. pH 7.52, Pco2 28 mm Hg
4. During the assessment of a laboring client, the nurse notes
that the FHT are loudest in the upper-right quadrant. The
infant is most likely in which position?
a. Right breech presentation
b. Right occipital anterior presentation
c. Left sacral anterior presentation
d. Left occipital transverse presentation
5. A client is hypovolemic and plasma expanders are not
available. The nurse anticipates that which of the following
solutions available on the nursing unit will be prescribed
by the physician?
a. 5% dextrose in water
b. 0.9% sodium chloride
c. 0.45% sodium chloride
d. 5% dextrose in 0.45% sodium chloride
6. A 68-year-old woman is diagnosed with thrombocytopenia
due to acute lymphocytic leukemia. She is admitted to the
hospital for treatment. The nurse should assign the
patient:
a. to a private room so she will not infect other
patients and health care workers.
b. to a private room so she will not be infected by
other patients and health care workers.
c. to a semiprivate room so she will have
stimulation during her hospitalization.
d. to a semiprivate room so she will have the
opportunity to express her feelings about her
illness.
7. A client who has undergone preadmission testing has had
blood drawn for serum laboratory studies, including
a complete blood count, coagulation studies, and
electrolytes and creatinine levels. Which of the following
results should be reported to the surgeon's office by the
nurse, knowing that it could cause surgery to be
postponed?
a. sodium, 141 mEq/L
b. hemoglobin, 8.0 g/dL
c. platelets, 210,000 mm3
d. serum creatinine, 0.8 mg/dL
8. A client with gastroesophagel reflux disease (GERD) has
received extensive client teaching about the disease and
related home care. Which statement by the client suggests
that the client is implementing the teaching?
a. “I usually drink a small glass of water before
bed.”
b. “I avoid food such as celery and bran cereal.”
c. “I changed from butter to margarine.”
d. “I quit drinking coffee and cola drinks.”
9. Which complication of cardiac catheterization should the
nurse monitor for in the initial 24 hours after the
procedure?
a. angina at rest
b. thrombus formation
c. dizziness
d. falling blood pressure
10. During hospital rounds, a nursing supervisor smells smoke
coming from a client’s bathroom. She opens the bathroom
door and finds the client unresponsive on the floor and the
waste can on fire. Which is her most appropriate
response?
a. Drag the client from the bathroom and close the
door.
b. Activate the fire alarm located outside the
client’s room.
c. Move the waste can to the shower and turn the
shower on.
d. Call for help from other staff members.
11. The nurse is speaking at a community meeting about
personal responsibility for health promotion. A participant
asks about chiropractic treatment for illnesses. What
should be the focus of the nurse’s response?
a. Electrical energy fields
b. Spinal column manipulation
c. Mind-body balance
d. Exercise of joints
12. A client with Parkinsonism is having problems with
ambulation and is experiencing wavering and stumbling.
Which client teaching would be most beneficial in
preventing the client from falling?
a. Keep the arms as still as possible when walking.
b. Walk with the feet spaced at hip width.
c. Maintain a slightly forward-leaning position.
d. Focus eyes on the level of the horizon.
13. A nurse enters a client’s room to discover that the client
has no pulse or respirations. After calling for help, the first
action the nurse should take is
a. Start a peripheral IV
b. Initiate closed-chest massage
c. Establish an airway
 d. Obtain the crash cart
14. A client thrombocyte count is 510,000. Which nursing
intervention is important?
a. Observe for nosebleeds
b. Use a manual sphygmomanometer
c. Encourage fluid intake
d. Minimize physical activity
15. A parent asks the school nurse how to eliminate lice from
their child. What is the most appropriate response by the
nurse?
a. Cut the child’s hair short to remove the nits
b. Apply warm soaks to the head twice daily
c. Wash the child’s linen and clothing in a bleach
solution
d. Apply pediculicides
16. Which assessment of the lungs by auscultation would the
nurse expect to evaluate if a client has a left lower lobe
consolidation?
a. Absent breath sounds
b. Bronchophony
c. Vesicular breath sounds
d. Wheezes
17. A nurse reviews a client's electrolyte laboratory report and
notes that the potassium level is 3.2 mEq/L. Which of the
following would the nurse note on the electrocardiogram
as a result of the laboratory value?
a. U waves
b. absent P waves
c. elevated T waves
d. elevated ST segment
18. Which plan would be most appropriate for a 34-week
pregnant woman who is being treated with magnesium
sulphate and bed rest for pregnancy induced
hypertension?
a. Assessing the equality of pedal pulse
b. Assessing the abdominal circumference
c. Assessing for an increase in urine output
d. Obtaining the client’s daily weight
19. A nurse reviews the arterial blood gas results of client and
notes the following: pH 7.45, Pco2 of 30 mm Hg, and HCO3
of 22 mEq/L. The nurse analyzes these results as indicating
which condition?
a. metabolic acidosis, compensated
b. respiratory alkalosis, compensated
c. metabolic acidosis, uncompensated
d. respiratory alkalosis, uncompensated
20. A client with inflammatory bowel disease is placed on a
daily dose of cyclosporine (Sandimmune) in an oral
solution form. Which behaviour by the client demonstrates
knowledge of how to take the drug?
a. He mixes it in a citrus juice and stirs it well
b. He waits at least 30 minutes to take the drug
after mixing it in a solution
c. After taking the medication, he adds water to
the container and drinks that too
d. He uses a plastic or Styrofoam cup to mix the
medication solution
21. The nurse hears an attending physician asking an intern to
prescribe a hypotonic intravenous (IV) solution for a client.
Which of the following IV solutions would the nurse
expect the intern to prescribe?
a. 5% dextrose in water
b. 10% dextrose in water
c. 0.45% sodium chloride
d. 5% dextrose in 0.9% sodium chloride
22. A 25-year-old client with a recent history of sinusitis
demonstrates a positive Brudzinski sign. The therapeutic
approach by the nurse that has the highest priority is:
a. Controlling intracranial pressure
b. Administering prescribed antibiotics
c. Adding pads to the side rails of the bed
d. Hydrating the patient with 0.45% Saline
23. A nurse has just reassessed the condition of a
postoperative client who was admitted 1 hour ago to the
surgical unit. The nurse plans to monitor which of the
following parameters most carefully during the next hour?
a. urinary output of 20 ml/hr
b. temperature of 37.6 C (99.6F)
c. blood pressure of 100/70 mmHg
d. serous drainage on the surgical dressing
24. The nurse observes that a fire has started in the client’s
room. Which action should the nurse take first?
a. Confine the fire to the client’s room
b. Extinguish the fire
c. Pull the fire alarm
d. Rescue the client
25. A client is admitted to the emergency room with renal
calculi and is complaining of moderate to severe flank pain
and nausea. The client’s temperature is 100.8 degrees
Fahrenheit. The priority nursing goal for this client is
a. Maintain fluid and electrolyte balance
b. Control nausea
c. Manage pain
d. Prevent urinary tract infection
26. Which assignment would be appropriate for the labor and
delivery (L&D) nurse who will be working for one shift on
the Medical Surgical Unit?
a. A 3-year-old with croup
b. A 30-year-old with malignant hypertension
c. A 40-year-old with unstable angina
d. A 50-year-old with congestive heart failure
27. The nurse is performing a neurological assessment on a
client post right CVA. Which finding, if observed by the
nurse, would warrant immediate attention?
a. Decrease in level of consciousness
b. Loss of bladder control
c. Altered sensation to stimuli
d. Emotional ability
28. After establishing IV access, what would be the best for
the nurse to document immediately after procedure?
a. The type of catheter used and number of
venepuncture attempts
b. The type of IV fluid hung and equipment used
c. The date, time, venipuncture site, type and
gauge of catheter, and IV fluid hung
d. Type amount and flow rate of IV fluid, condition
of IV site
29. A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The
health care provider has written a new order to give
metoprolol (Lopressor) 25 mg. B.I.D. In assessing the client
prior to administering the medications, which of the
following should the nurse report immediately to the
health care provider?
a. Blood pressure 94/60
b. Heart rate 76
c. Urine output 50 ml/hour
d. Respiratory rate 16
30. Which statement made by the new mother indicates an
understanding of screening for PKU for her newborn son
who she is breastfeeding?
a. “I will have him tested 24 hours after birth.”
b. “I will return to the clinic in 48 hours for the
screening.”
c. “I will return in 1 week to obtain blood samples.”
d. “I will return in 1 month for the screening.”
31. Discharge instructions for a client taking alprazolam
(Xanax) should include which of the following?
a. Sedative hypnotics are effective analgesics
b. Sudden cessation of alprazolam (Xanax) can
cause rebound insomnia and nightmares
c. Caffeine beverages can increase the effect of
sedative hypnotics
d. Avoidance of excessive exercise and high
temperatures is recommended
32. Which of these schedules would be most appropriate to
recommend to a pre-menopausal woman regarding her
self-breast exam?
a. One week prior to monthly period
b. One week after the menstrual period
c. During every shower
d. The same day monthly
33. A nurse caring for a group of clients reviews the
electrolyte laboratory results and notes a potassium level
of 5.5 mEq/L on one client's laboratory report. The nurse
understands that which client is at highest risk for the
development of a potassium value at this level?
a. the client with colitis
b. the client with Cushing's syndrome
c. the client who has been overusing laxatives
d. the client who has sustained a traumatic burn
34. The nurse is assessing a child with a tentative diagnosis of
appendicitis. This diagnosis is most often manifested by:
a. Sharp pain with extreme gastric distention
b. Rebound tenderness in the right lower
abdominal quadrant, with decreased bowel
sounds
c. Growing pain radiating to the lower back
d. Pain on light palpitation in epigastric area with
diarrhea
35. A client is receiving a continuous intravenous infusion of
heparin sodium to treat deep vein thrombosis. The
client's activated partial thromboplastin time (aPTT) time is
65 seconds. The client's baseline before the initiation of
therapy was 30 seconds. The nurse anticipates that which
action is needed?
a. discontinuing the heparin infusion
b. increasing the rate of the heparin infusion
c. decreasing the rate of heparin infusion
d. leaving the rate of the heparin infusion at is
36. What is the priority of care after the urinary catheter is
removed?
a. Encourage client to eliminate fluid intake
b. Document size of catheter and client’s tolerance
of procedure
c. Evaluate client for normal voiding
d. Documentation of client teaching
37. A client receiving a transfusion of packed red blood
cells (PRBCs) begins to vomit. The nurse takes the
client's blood pressure and it is 90/50 mm Hg, from a
baseline of 125/78 mm Hg. The client's temperature is
100.8F orally, from a baseline of 99.2F orally. The nurse
determines that the client may be experiencing which
complication of a blood transfusion?
a. Septicaemia
b. Hyperkalemia
c. Circulatory overload
d. Delayed transfusion reaction
38. Which clinical findings indicate a complication from
diabetes insipidus?
a. Urine specific gravity 1.001
b. Serum sodium 135
c. Urine output greater than 200cc/hr
d. Weight loss of 2 lbs
39. A physician prescribes home health nurse visits for a child
discharged with Reye's syndrome. During a home visit, a
nurse instructs the parents about the residual effects of
Reye's syndrome. Which statement, if made by the
parents, indicates a need for further instruction?
a. we need to check for jaundiced skin and eyes
everyday
b. we need to have the child nap during the day to
provide rest
c. we need to decrease the stimuli at home to
prevent increased intracranial pressure
d. we need to give frequent, small, nutritious meals
to decrease the amount of vomiting
40. Which nursing actions is most appropriate for a client
receiving a tube feeding around the clock?
a. Rinse the bag and change the formula every 4
hours
b. Rinse the bag and change the formula every shift
c. Change the bag and formula every shift
 d. Rinse the bag and change the formula every 2
hours
41. What would the nurse expect to see while assessing the
growth of children during their school age years?
a. Decreasing amounts of body fat and muscle
mass
b. Little change in body appearance from year to
year
c. Progressive height increase of 4 inches each year
d. Yearly weight gain of about 5.5 pounds per year
42. An adult comes to the clinic with complaints of frequency
and burning on urination. The nurse expects that what test
will be ordered for the client?
a. Clean catch urine for culture and sensitivity
b. CBC and electrolytes
c. Cystoscopy
d. Strain of all urine for calculi
43. A child who has recently been diagnosed with cystic
fibrosis is in a pediatric clinic where a nurse is performing
an assessment. Which later finding of this disease would
the nurse not expect to see at this time?
a. Positive sweat test
b. Bulky greasy stools
c. Moist, productive cough
d. Meconium ileus
44. The nurse is inserting an indwelling urinary catheter in an
adult woman. The nurse locates landmarks before
inserting the catheter. The urethral opening is located:
a. Above the clitoris
b. Behind the vagina
c. Between the clitoris and vagina
d. Between the vagina and rectum
45. While assessing a 1 month-old infant, which finding should
the nurse report immediately?
a. Abdominal respirations
b. Irregular breathing rate
c. Inspiratory grunt
d. Increased heart rate with crying
46. The nurse returns to the nurse’s station after making client
rounds and finds four phone messages. Which of the
following messages should the nurse return first?
a. A client with hepatitis A who states, “My arms
and legs are itching.”
b. A client with a 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 arthritis who states, “I am having
trouble sleeping at night.”
47. A client is recovering from a hip replacement and is taking
Tylenol #3 every 3 hours for pain. In checking the client,
which finding suggests a side effect of the analgesic?
a. Bruising at the operative site
b. Elevated heart
c. Decreased platelet count
d. No bowel movement for 3 days
48. Following hip replacement surgery, an elderly client is
ordered to begin ambulation with a walker. Which of the
following statements by the nurse is best?
a. “Sit in a low chair for ease in getting up to use
the walker.”
b. “Make sure rubber caps are in place on all four
legs of the walker.”
c. “You will begin weight-bearing on the affected
hip soon.”
d. “Practice tying your own shoes before you begin
ambulation.”
49. A nurse reviews the electrolyte results of an assigned
client and notes that the potassium level is 5.4 mEq/L.
Which of the following would the nurse expect to note on
the electrocardiogram as a result of the laboratory value?
a. ST depression
b. inverted T wave
c. prominent U wave
d. tall peaked T waves
50. A 22-year-old woman comes to the hospital at term in the
early stages of labor. A diagnosis of complete placenta
previa is made. It would be MOST important for the nurse
to take which of the following actions?
a. Start an IV of terbutaline (Brethine) and monitor
the patient’s vital signs closely.
b. Prepare the patient for an immediate cesarean
section.
c. Maintain the patient on bedrest until
spontaneous vaginal delivery is achieved.
d. Monitor the patient’s length and duration of
contractions.
51. An adult female client has a hemoglobin level of 10.8 g/dL.
The nurse interprets that this result is most likely caused
by which of the following conditions noted in the client's
history?
a. Dehydration
b. heart failure
c. iron deficiency anemia
d. chronic obstructive pulmonary disease
52. Which of the following nursing observations would
indicate to the nurse that a child with epiglottitis is having
an early complication of hypoxemia?
a. Heart rate of 148 beats per minute.
b. Bluish discoloration of the skin.
c. Bluish discoloration around the mouth.
d. Difficulty swallowing.
53. The nurse is told by a physician that a client in
hypovolemic shock will require plasma expansion. The
nurse anticipates receiving an order to transfuse which
product?
a. Albumin
b. Platelets
c. Cryoprecipitate
d. Packed red blood cells
54. The neonatal nurse is instructing the family of a newborn
about an apnea monitor. The nurse should be MOST
concerned if a family member makes which of the
following statements?
a. “We will be able to leave our baby for brief
periods of time.”
b. “We plan to sleep by our baby’s crib.”
c. “We can remove the monitor during our baby’s
bath.”
d. “A family member will closely watch the monitor
all the time.
55. A nurse is reviewing the laboratory results for a child
scheduled for tonsillectomy. The nurse determines that
which laboratory value is most significant to review?
a. Creatinine
b. Prothrombin
c. Sedimentation rate
d. Blood urea nitrogen level
56. A 20-year-old client has a cast applied for a fracture of the
right femur. Three hours later, the client complains that it
is hot and painful under his cast. Which of the following is
the MOST appropriate action for the nurse to take?
a. Assess the cast for wet spots and increase air
circulation in the room.
b. Check the circulation in his casted extremity and
change the client’s position.
c. Take the client’s temperature and observe him
for other signs of infection.
d. Medicate the client for pain and notify the
physician of his complaint.
57. At a community health fair the blood pressure of a 62
year-old client is 160/96. The client states “My blood
pressure is usually much lower.” The nurse should tell the
client to
a. go get a blood pressure check within the next 48
to 72 hours
b. check blood pressure again in 2 months
c. see the health care provider immediately
d. visit the health care provider within 1 week for a
BP check
58. Which of the following plans would be MOST appropriate
for the nurse to use to prepare a 10-year-old for a cardiac
catheterization?
a. Show a videotape specifically prepared for
children about cardiac catheterization.
b. Provide the child with a pamphlet about the
procedure and encourage him to read it.
c. Draw a picture of a heart and explain where the
tube will go and what the doctor will see.
d. Present a puppet show explaining the anatomy
and physiology of the heart.
59. The home health nurse visits a male client to provide
wound care and finds the client lethargic and confused. His
wife states he fell down the stairs 2 hours ago. The nurse
should
a. Place a call to the client’s health care provider
for instructions
b. Send him to the emergency room for evaluation
c. Reassure the client’s wife that the symptoms are
transient
d. Instruct the client’s wife to call the doctor if his
symptoms become worse
60. Which of the following nursing actions is MOST important
to provide a patient with effective pain relief?
a. Teach the patient about his pain.
b. Establish a trusting relationship with the patient.
c. Determine how various relaxation techniques
affect the pain.
d. Provide alternative measures to relieve pain.
61. The nurse practicing in a maternity setting recognizes that
the post mature fetus is at risk due to
a. Excessive fetal weight
b. Low blood sugar levels
c. Depletion of subcutaneous fat
d. Progressive placental insufficiency
62. An adult woman is admitted to an acute locked psychiatric
unit one month prior to an election. She requests the
opportunity to vote in the upcoming election. Which of the
following responses by the nurse is BEST?
a. “You are not eligible to vote because you are a
psychiatric patient.”
b. “I’ll make the appropriate arrangements for you
to vote.”
c. “You may vote only if you are discharged by
Election Day.”
d. “I’ll contact the Election Board to see if you are
registered to vote.”
63. The nurse is caring for a client with clinical depression who
is receiving a MAO inhibitor. When providing instructions
about precautions with this medication, which action
should the nurse stress to the client as important?
a. Avoid cheese and chocolate
b. Take frequent naps
c. Take the medication with milk
d. Avoid walking without assistance
64. A client is scheduled for a traditional abdominal
cholecystectomy. Which of the following statements, if
made by the nurse to the client the night before surgery, is
MOST important?
a. “It is important for you to eat foods from every
level of the food pyramid and avoid excessive
fats in your diet.”
b. “Place the pillow against your abdomen, take
three deep breaths, hold your breath, and then
cough two or three times.”
c. “There will be a machine available to you after
surgery for you to use to continuously receive
pain medication.”
d. “You may come back from surgery with a tube in
your nose that drains your gall bladder.”
65. A nurse caring for a group of clients reviews the
electrolyte laboratory results and notes a sodium level of
130 mEq/L on one client's laboratory report. The nurse
understands that which client is at highest risk for the
development of sodium value at this level?
a. the client with renal failure
b. the client who is taking diuretics
c. the client with hyperaldosteronism
 d. the client who is taking corticosteroids
66. A 22-year-old mother of a 4-year-old boy comes to the
antepartal clinic. Her second pregnancy has just been
confirmed. During this initial visit, it MOST important for
the nurse to
a. assess the client’s feelings about pregnancy,
labor, and delivery.
b. obtain a history of the client’s last labor and
delivery.
c. determine how the client’s 4-year-old feels
about the pregnancy.
d. identify the client’s general health needs.
67. The nurse is teaching a client who has iron deficiency
anemia about foods she should include in her diet. The
nurse determines that the client understands the dietary
modifications if she selects which of the following from her
menu?
a. nuts and milk
b. coffee and tea
c. cooked rolled oats and fish
d. oranges and dark leafy vegetables
68. The nurse is caring for a client with a perforated bowel
secondary to a bowel obstruction. At the time the
diagnosis is made, which of the following should be a
priority in the nursing care plan?
a. Maintain the client in a supine position.
b. Notify the client’s next-of-kin.
c. Prepare the client for emergency surgery.
d. Remove the nasogastric tube.
69. A physician tells a client that the client needs a blood
transfusion and that the blood sample must be drawn first
for blood typing and crossmatching. After the physician
leaves, the client asks the nurse, "What exactly isblood
type, anyway?" The nurse responds with which of the
following statements?
a. the blood type represents an antigen found on
the surface of the red blood cells
b. the blood type represents an antibody found on
the surface of the red blood cells
c. the blood type represents an antibody that
normally circulates in the blood plasma
d. the blood type represents an antigen that
normally circulates in the blood plasma
70. The doctor writes an order for piperacillin (Pipracil) 3 g IV
q6h for an adult client. Before administering this drug, the
nurse should:
a. check for known allergies to medications.
b. ensure that the client’s respiratory rate is over
12.
c. administer dexamethasone sodium phosphate
(Decadron) 2 mg IV stat.
d. check the client’s blood pressure both sitting and
standing
71. A child is scheduled for a tonsillectomy. A nurse plans care,
knowing that which of the following would present the
highest risk of aspiration during surgery?
a. difficulty in swallowing
b. bleeding during surgery
c. exudate in the throat area
d. presence of loose teeth
72. A mother brings her 17-month-old son to the well-baby
clinic for a routine check-up. She confides to the nurse that
she is concerned because her son sucks his thumb,
especially at night when he is put to bed. Which of the
suggestions by the nurse would be BEST?
a. “If you want the behavior to stop put a negative
reinforcer, such as red pepper, on this thumb.”
b. “Don't intervene at this time. This behavior
usually subsides after 24 months of age.”
c. “What you are seeing is a common form of self-
stimulation. You should discourage this
behavior.”
d. “This behavior will cause malformation of his
teeth. You should wrap his thumb at bedtime.”
73. The hospital has sounded the call for a disaster drill on the
evening shift. Which of these clients would the nurse put
first on the list to be discharged in order to make a room
available for a new admission?
a. A middle aged client with a history of being
ventilator dependent for over 7 years and
admitted with bacterial pneumonia five days ago
b. A young adult with diabetes mellitus Type 2 for
over 10 years and admitted with antibiotic
induced diarrhea 24 hours ago
c. An elderly client with a history of hypertension,
hypercholesterolemia and lupus, and was
admitted with Stevens-Johnson syndrome that
morning
d. An adolescent with a positive HIV test and
admitted for acute cellulitus of the lower leg 48
hours ago
74. The nurse is caring for clients in the outpatient clinic. A
young adult female is seeking help for weight loss. Her
weight is 257 pounds, and she is 5′7″ tall. Which of the
following indicates the most appropriate diet choices for
breakfast?
a. Applesauce, cream of wheat, toast.
b. Scrambled eggs and toast, one slice of bacon.
c. One glass of grapefruit juice.
d. Bagel with two ounces of cream cheese and a
banana.
75. Which of the following should the nurse implement to
prepare a client for a KUB (Kidney, Ureter, Bladder)
radiograph test?
a. Client must be NPO before the examination
b. Enema to be administered prior to the
examination
c. Medicate client with Lasix 20 mg IV 30 minutes
prior to the examination
d. No special orders are necessary for this
examination
76. A toddler admitted with an elevated blood lead level is to
be treated with intramuscular (IM) injections of calcium
disodium edetate (Calcium EDTA) and dimercaprol (BAL).
Which of the following nursing actions should have the
highest priority?
 a. Keep a tongue blade at the bedside.
b. Encourage the child to participate in play
therapy.
c. Apply cool soaks to the injection site.
d. Rotate the injection sites.
77. The nurse is caring for a client who had a total hip
replacement 4 days ago. Which assessment requires the
nurse’s immediate attention?
a. I have bad muscle spasms in my lower leg of the
affected extremity.
b. “I just can’t ‘catch my breath’ over the past few
minutes and I think I am in grave danger.”
c. “I have to use the bedpan to pass my water at
least every 1 to 2 hours.”
d. “It seems that the pain medication is not working
as well today.”
78. The nurse is instructing a client being discharged on
tranylcypromine sulfate (Parnate). The nurse knows
further instruction is needed if the client makes which of
the following statements?
a. “To celebrate, my wife and I are going out for
pepperoni pizza and wine tonight.”
b. “I plan to use sunblock at the beach this
summer.”
c. “When I get home, I am going to start a diet so I
can lose some weight.”
d. “Now that I feel so much better, I have more
energy”
79. An antibiotic IM injection for a 2 year-old child is ordered.
The total volume of the injection equals 2.0 ml The correct
action is to:
a. Administer the medication in 2 separate
injections
b. Give the medication in the dorsal gluteal site
c. Call to get a smaller volume ordered
d. Check with pharmacy for a liquid form of the
medication
80. A college student was in a motor vehicle accident six
months ago. Although he was minimally injured, his friend
was killed. The client comes to Student Health Services
with the complaints of not being able to study, not
sleeping, and thinking he’s “going crazy.” It is MOST
important for the nurse to:
a. perform a complete physical and social history.
b. obtain a complete drug and alcohol history,
including reports from a drug screen.
c. review the significant events of the last year.
d. explore how he coped with the motor vehicle
crash and his friend’s death.
81. A nurse is reviewing a client's laboratory report and notes
that the serum calcium level is 4.0 mg/dL. The nurse
understands that which condition most likely caused this
serum calcium level?
a. prolonged bed rest
b. renal insufficiency
c. hyperparathyroidism
d. excessive ingestion of vitamin D
82. A client who is receiving hydralazine (Apresoline) q6h has a
blood pressure of 90/60. Which of the following nursing
actions would be MOST appropriate?
a. Withhold the medication.
b. Check the urinary output.
c. Administer the medication.
d. Increase the potassium intake.
83. A client is being weaned from parenteral nutrition (PN)
and is expected to begin taking solid food today. The
ongoing solution rate has been 100 ml/hr. A nurse
anticipates that which of the following orders regarding
the PN solution will accompany the diet order?
a. discontinue the PN
b. decrease PN rate to 50 ml/hr
c. hang 1000 ml 0.9% normal saline
d. continue current infusion rate orders for PN
84. A 34-year-old multipara comes to the prenatal clinic during
her fifth month of pregnancy. The client complains to the
nurse that her breasts are sensitive and sore. Which of the
following suggestions by the nurse is BEST?
a. Apply warm compresses to your breasts and take
two aspirin as needed.
b. Massage your breasts with lotion and wear
loose-fitting clothing.
c. Apply cold compresses to your breasts and wear
a well-fitting, supportive bra.
d. Take a diuretic once a day and avoid touching
your breasts.
85. The nurse enters a client's room to assess the client, who
began receiving a blood transfusion 45 minutes earlier,
and notes that the client is flushed and dyspneic. On
assessment, the nurse auscultates the presence of crackles
in the lung bases. The nurse determines that his client
most likely is experiencing which complication of blood
transfusion therapy?
a. Bacteremia
b. Hypovolemia
c. Fluid overload
d. Transfusion reaction
86. The nurse is caring for a patient with hyperparathyroidism.
Which symptom is MOST important for the nurse to report
to the next shift?
a. Abdominal discomfort.
b. Hematuria.
c. Muscle weakness.
d. Diaphoresis.
87. After a tonsillectomy, a nurse reviews the physician's
postoperative orders. Which of the following physician's
orders does the nurse question?
a. monitor for bleeding
b. suction every 2 hours
c. give no milk or milk products
d. give clear, cool liquids when awake
88. Two days after admission, a client’s sputum culture is
reported as positive for tuberculosis. While awaiting
orders from the physician, the nurse should:
a. initiate measures to transfer the client to a
tuberculosis unit.
 b. institute measures to initiate airborne
precautions.
c. arrange for all of the client’s personal effects to
be decontaminated.
d. notify the client’s family that they have been
exposed to a contagious disease.
89. A client has been newly diagnosed with hypothyroidism
and will take levothyroxine (Synthroid) 50 mcg/day by
mouth. As part of the teaching plan, the nurse emphasizes
that this medication:
a. Should be taken in the morning
b. May decrease the client’s energy level
c. Must be stored in a dark container
d. Will decrease the client’s heart rate
90. A 33-year-old woman comes to the local outpatient clinic
for complaints of dizziness and palpitations. Her physical
exam and laboratory results are normal. She reports that
the company she owns is on the verge of bankruptcy.
Which of the following responses, if made to the client by
the nurse, would be BEST?
a. “When did you first notice these symptoms?”
b. “Have you shared this information with
anyone?”
c. “Are you concerned about your financial
difficulties?”
d. “Would you like to discuss your situation with
me?”
91. The nurse is giving discharge teaching to a client 7 days
post myocardial infarction. He asks the nurse why he must
wait 6 weeks before having sexual intercourse. What is the
best response by the nurse to this question?
a. “You need to regain your strength before
attempting such exertion.”
b. “When you can climb 2 flights of stairs without
problems, it is generally safe.”
c. “Have a glass of wine to relax you, then you can
try to have sex.”
d. “If you can maintain an active walking program,
you will have less risk.”
92. A client had a radical mastectomy for cancer in her right
breast. After the client returns to the unit, which of the
following actions, if performed by the nurse, would be
MOST appropriate?
a. Position the client on her left side with her right
arm protected in a sling.
b. Position the client on her right side with her right
arm elevated.
c. Position the client in semi-Fowler’s position with
her right arm elevated.
d. Position the client in the prone position with her
right arm elevated.
93. A client has been taking furosemide (Lasix) for the past
week. The nurse recognizes which finding may indicate the
client is experiencing a negative side effect from the
medication?
a. Weight gain of 5 pounds
b. Edema of the ankles
c. Gastric irritability
d. Decreased appetite
94. When the nurse walks into a client’s room, the client
states, “I just love hot-blooded redheads.” The client pats
his bed and says, “Why don’t you sit down here and get off
your feet for a while.” Which of the following responses by
the nurse is BEST?
a. “I feel very uncomfortable when you make those
suggestive remarks. It makes it difficult for me to
do my job.”
b. “I don’t think my husband or your wife would
like me doing that.”
c. “You must be very lonesome. I’ll come back later
and spend some time with you.”
d. “I bet you flirt with all the nurses like that.”
95. A client with amyotrophic lateral sclerosis has a
percutaneous endoscopic gastrostomy (PEG) tube for the
administration of feedings and medications. Which nursing
action is appropriate?
a. Pulverize all medications to a powdery condition
b. Squeeze the tube before using it to break up
stagnant liquid
c. Cleanse the skin around the tube daily with
hydrogen peroxide
d. Flush adequately with water before and after
using the tube
96. The nurse answers the psychiatric unit’s desk phone. The
caller identifies himself as the husband of a patient and
inquires about her condition. Which of the following
responses by the nurse is most appropriate?
a. “I may not deny or confirm any patient’s
presence in this hospital.”
b. “Patients are not allowed to use his phone.
Please call the patient’s phone number directly.”
c. “I cannot give information over the phone. If you
come in we can discuss her condition.”
d. “I will have to ask her if she wishes for me to give
out that information.”
97. A nurse is assessing a client with a suspected diagnosis of
hypocalcemia. Which of the following clinical
manifestations would the nurse expect to note in the
client?
a. Twitching
b. negative trousseau's sign
c. hypoactive bowel sounds
d. hypoactive deep tendon reflexes
98. Several days after a client had a myocardial infarction, the
physician placed him on a 2-gm sodium diet. Which of the
following selections would indicate to the nurse an
understanding of the diet?
a. Scrambled egg, orange slices, and milk.
b. Instant oatmeal, toast, and orange juice.
c. Poached egg, bacon, and milk
d. Biscuit, fruit cup, and sausage.
99. A client receiving parenteral nutrition (PN) complains of
headache. A nurse notes that the client has an
increased blood pressure, bounding pulse, jugular vein
distention, and crackles bilaterally. The nurse interprets
 that the client is experiencing which complication of PN
therapy.

a. sepsis
b. air embolism
c. hypervolemia
d. hyperglycemia

100. The nurse is leading a class for expectant mothers. Which

of the following comments would indicate to the nurse
that a pregnant woman understands the recommended
dietary caloric increase for pregnancy?
a. “I will need to double my calorie intake since I
am now eating for two of us.”
b. “I can add an additional 500 calories by drinking
milkshakes.”
c. “I need to add 300 calories by increasing my
intake of the four basic food groups.”
d. “I really need to watch my calorie intake so I will
not gain too much weight.”