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Which of the following connective tissue disorders is characterized by insoluble collagen

being formed and accumulating excessively in the tissues?

Rheumatoid arthritis


Systemic lupus erythematosus

Polymyalgia rheumatic

2. Helen, a client with myasthenia gravis, begins to experience increased difficulty in

swallowing. To prevent aspiration of food, the nursing action that would be most
effective would be to:

Assess her respiratory status before and after meals

Change her diet order from soft foods to clear liquids

Coordinate her meal schedule with the peak effect of her medication

Place an emergency tracheostomy set in her room

3. After Billroth II Surgery, the client developed dumping syndrome. Which of the
following should the nurse exclude in the plan of care?

Reduce the amount of simple carbohydrate in the diet

Sit upright for at least 30 minutes after meals

Eat small meals every 2-3 hours

Take only sips of H2O between bites of solid food

4. After the acute phase of congestive heart failure, the nurse should expect the dietary
management of the client to include the restriction of:





5. A Sengstaken-Blakemore tube is inserted in the effort to stop the bleeding esophageal

varices in a patient with complicated liver cirrhosis. Upon insertion of the tube, the client
complains of difficulty of breathing. The first action of the nurse is to:

Notify the MD

Monitor VS

Encourage him to take deep breaths

Deflate the esophageal balloon

6. The nurse is attending a bridal shower for a friend when another guest, who happens to
be a diabetic, starts to tremble and complains of dizziness. The next best action for the
nurse to take is to:

Encourage the guest to eat some baked macaroni

Offer the guest a cup of coffee

Give the guest a glass of orange juice

Call the guests personal physician

7. Included in the plan of care for the immediate post-gastroscopy period will be:

Assess for pain and medicate as ordered

Assess gag reflex prior to administration of fluids

Maintain NGT to intermittent suction

Measure abdominal girth every 4 hours

8. A client has Gastroesophageal Reflux Disease (GERD). The nurse should teach the client
that after every meals, the client should

Rest in sitting position

Lie down at least 30 minutes

Drink plenty of water

Take a short walk

9. Mr. Alzawar is in continuous pain from cancer that has metastasized to the bone. Pain
medication provides little relief and he refuses to move. The nurse should plan to:

Complete A.M. care quickly as possible when necessary

Reassure him that the nurses will not hurt him

Let him perform his own activities of daily living

Handle him gently when assisting with required care

10. After surgery, Gihan returns from the Post-anesthesia Care Unit (Recovery Room) with a
nasogastric tube in place following a gall bladder surgery. She continues to complain of
nausea. Which action would the nurse take?

Change the patients position.

Check the patency of the NGT for any obstruction

Administer the prescribed antiemetic.

Call the physician immediately

11. Mr. Kalifa a client with CHF, has been receiving a cardiac glycoside, a diuretic, and a
vasodilator drug. His apical pulse rate is 44 and he is on bed rest. The nurse concludes
that his pulse rate is most likely the result of the:

Bed-rest regimen

Cardiac glycoside



12. A client with leukemia is undergoing radiation therapy to the brain and spinal cord. In
planning care for this client, the nurse would include which nursing intervention?

A dandruff shampoo twice daily

Not allowing the client to use a hat or scarf

Avoiding washing off the target's marks

A scalp ointment to prevent dryness

13. A 60 year old male client comes into the emergency department with complaints of
crushing substernal chest pain that radiates to his shoulder and left arm. The admitting

diagnosis is acute myocardial infarction (MI). Immediate admission orders include

oxygen by nasal cannula at 4L/minute, blood work, a chest radiograph, a 12-lead
electrocardiogram (ECG) and 2 mg of morphine sulfate given intravenously. The nurse
should first:

obtain a blood work

administer the morphine

order the chest radiograph

obtain a 12 lead ECG

14. Nurse Jamela is assigned to care for a client who has returned to the nursing unit after
left nephrectomy. Nurse Jamelas highest priority would be


Hourly urine output

Able to sips clear liquid

Able to turn side to side

15. The nurse is teaching the client with right leg fracture regarding the physicians order
for partial weight bearing status. The client understands the health teaching if he

I am allowed to put 40% of my weight on my right leg

I am allowed to put 10% of my actual weight on my right leg

I am not allowed to let my fractured leg touch the floor

I should not bear weight on my fractured leg

16. Which of the following signs and symptoms would Nurse Maureen include in teaching
plan as an early manifestation of laryngeal cancer?

Airway obstruction




17. Noor is ordered laboratory tests after she is admitted to the hospital for angina. The
isoenzyme test that is the most reliable early indicator of myocardial insult is:





18. The emergency room nurse admits a child who experienced a seizure at school. The
father comments that this is the first occurrence, and denies any family history of
epilepsy. What is the best response by the nurse?

Since this was the first convulsion, it may not happen again.

Long term treatment will prevent future seizures

The seizure may or may not mean your child has epilepsy.

Do not worry. Epilepsy can be treated with medications

19. A female client is experiencing painful and rigid abdomen and is diagnosed with
perforated peptic ulcer. A surgery has been scheduled and a nasogastric tube is inserted.
The nurse should place the client before surgery in

Supine position

Semi-fowlers position

Dorsal recumbent position

Sims position

20. Amir who has undergone thoracic surgery has chest tube connected to a water-seal
drainage system attached to suction. Presence of excessive bubbling is identified in waterseal chamber, the nurse should

Recognize the system is functioning correctly

Check the system for air leaks

Strip the chest tube catheter

Decrease the amount of suction pressure

21. Karina a client with myasthenia gravis is to receive immunosuppressive therapy. The
nurse understands that this therapy is effective because it:

Decreases the production of auto antibodies that attack the acetylcholine


Promotes the removal of antibodies that impair the transmission of impulses

Inhibits the breakdown of acetylcholine at the neuromuscular junction.

Stimulates the production of acetylcholine at the neuromuscular junction.

22. Which of the following statements reflect nursing interventions in the care of the patient
with osteoarthritis?

Provide an analgesic after exercise.

Encourage weight loss and an increase in aerobic activity.

Avoid the use of topical analgesics.

Assess for the gastrointestinal complications associated with COX-2 inhibitors

23. A client has suffered from fall and sustained a leg injury. Which appropriate question
would the nurse ask the client to help determine if the injury caused fracture?

Does the pain feel like the muscle was stretched?

Is the pain dull ache?

Does the discomfort feel like a cramp?

Is the pain sharp and continuous?
24. The laboratory of a male patient with Peptic ulcer revealed an elevated titer of
Helicobacter pylori. Which of the following statements indicate an understanding of this

Surgical treatment is necessary

No treatment is necessary at this time

This result indicates gastric cancer caused by the organism

Treatment will include Ranitidine and Antibiotics

25. A student nurse is assigned to a client who has a diagnosis of thrombophlebitis. Which
action by this team member is most appropriate?

Apply a heating pad to the involved site.

Provide active range-of-motion exercises to both legs at least twice every shift.

Elevate the clients legs 90 degrees.

Instruct the client about the need for bed rest.

26. The husband of a client asks the nurse about the protein-restricted diet ordered because
of advanced liver disease. What statement by the nurse would best explain the purpose of
the diet?

Most people have too much protein in their diets. The amount of this diet is

better forliver healing.


Because of portal hyperemesis, the blood flows around the liver and ammonia

made from protein collects in the brain causing hallucinations.


The liver heals better with a high carbohydrates diet rather than protein.

The liver cannot rid the body of ammonia that is made by the breakdown of

protein in the digestive system.

27. Nurse Perry is evaluating the renal function of a male client. After documenting urine
volume and characteristics, Nurse Perry assesses which signs as the best indicator of
renal function.

Pulse rate

Blood pressure


Distension of the bladder

28. Following a diagnosis of acute glomerulonephritis (AGN) in their 6 year-old child, the
parents remark: We just dont know how he caught the disease! The nurse's response is
based on an understanding that

The illness is usually associated with chronic respiratory infections

The disease is easily transmissible in schools and camps

It is not "caught" but is a response to a previous B-hemolytic strep infection

AGN is a streptococcal infection that involves the kidney tubules

29. The nurse is planning care for a client during the acute phase of a sickle cell vasoocclusive crisis. Which of the following actions would be most appropriate?
Administer analgesic therapy as ordered

Fluid restriction 1000cc per day

Encourage increased caloric intake

Ambulate in hallway 4 times a day

30. Which description of pain would be most characteristic of a duodenal ulcer?

Sharp pain in the epigastric area that radiates to the right shoulder

Gnawing, dull, aching, hungerlike pain in the epigastric area that is relieved by

food intake

A sensation of painful pressure in the midsternal area

RUQ pain that increases after meal

31. Mark has multiple abrasions and a laceration to the trunk and all four extremities says, I
cant eat all this food. The food that the nurse should suggest to be eaten first should be:

Meat loaf and strawberries

Meat loaf and coffee

Tomato soup and buttered bread

Tomato soup and apple pie

32. A female client with breast cancer is currently receiving radiation therapy for treatment.
The client is complaining of apathy, hard to concentrate on something, and feeling tired
despite of having time to rest and more sleep. These complains suggest symptoms of

radiation pneumonitis



advanced breast cancer

33. A client receiving heparin sodium asks the nurse how the drug works. Which of the
following points would the nurse include in the explanation to the client?

It inactivates thrombin that forms and dissolves existing thrombi.

It prevents conversion of factors that are needed in the formation of clots.

It dissolves existing thrombi.

It interferes with vitamin K absorption

34. The client presents with severe rectal bleeding, 16 diarrheal stools a day, severe
abdominal pain, tenesmus and dehydration. Because of these symptoms the nurse should
be alert for other problems associated with what disease?

Ulcerative colitis


Chrons disease


35. What instructions should the client be given before undergoing a paracentesis?

Strict bed rest following procedure


NPO 12 hours before procedure

Empty bladder before procedure

Empty bowel before procedure

36. Which of the drug of choice for pain controls the patient with acute pancreatitis?





37. Days after abdominal surgery, the clients wound dehisces. The safest nursing
intervention when this occurs is to

Approximate the wound edges with tapes

Cover the wound with sterile, moist saline dressing

Irrigate the wound with sterile saline

Hold the abdominal contents in place with a sterile gloved hand

38. A client with multiple injuries following a vehicular accident is transferred to the critical
care unit. He begins to complain of increased abdominal pain in the left upper quadrant.
A ruptured spleen is diagnosed and he is scheduled for emergency splenectomy. In
preparing the client for surgery, the nurse should emphasize in his teaching plan the:

Risk of the procedure with his other injuries

Presence of abdominal drains for several days after surgery

Complete safety of the procedure

Expectation of postoperative bleeding

39. A 3 year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the
nurse should

Use a heat lamp to reduce the drying time

Expose the cast to air and turn the child frequently

Turn the child as little as possible

Handle the cast with the abductor bar

40. What would be the primary goal of therapy for a client with pulmonary edema and heart

Enhance comfort

Improve respiratory status

Peripheral edema decreased

Increase cardiac output

41. A nurse wants to assess if the clients brachial plexus was compromised after undergoing
shoulder arthroplasty due to rheumatoid arthritis. To assess the cutaneous nerve status
which of the following would the nurse perform?

Ask the client move his thumb toward the palm and back to the neutral position

Let the client raise his forearm and monitor for flexion of the biceps


Have the client spread all the fingers wide and resist pressure.
Have the client grasp the nurses hand while noting the clients strength of the

first and second fingers

42. At a senior citizens meeting a nurse talks with a client who has diabetes mellitus Type 1.
Which statement by the client during the conversation is most predictive of a potential
for impaired skin integrity?

"I give my insulin to myself in my thighs."

"Here are my up and down glucose readings that I wrote on my calendar."

"Sometimes when I put my shoes on I don't know where my toes are."

"If I bathe more than once a week my skin feels too dry.

43. A newborn has been diagnosed with hypothyroidism. In discussing the condition and
treatment with the family, the nurse should emphasize

Administration of thyroid hormone will prevent problems

Physical growth/development will be delayed

They can expect the child will be mentally retarded

This rare problem is always hereditary

44. To promote continued improvement in the respiratory status of a client following chest
tube removal after a chest surgery for multiple rib fracture, the nurse should:

Encourage bed rest with active and passive range of motion exercises

Continue observing for dyspnea and crepitus

Encourage frequent coughing and deep breathing

Turn him from side to side at least every 2 hours

45. The client underwent Billroth surgery for gastric ulcer. Post-operatively, the drainage
from his NGT is thick and the volume of secretions has dramatically reduced in the last
2 hours and the client feels like vomiting. The most appropriate nursing action is to:

Irrigate the NGT with 50 cc of sterile

Discontinue the low-intermittent suction

Notify the MD of your findings

Reposition the NGT by advancing it gently NSS

46. A child in the Emergency Room is diagnosed with an acute episode of Croup (Acute
laryngotracheo - bronchitis). During the initial assessment, which of the following
finding would the nurse expect to find?

Inspiratory stridor with a brassy cough

Shallow respirations

Decreased aeration in lung fields

Diffuse expiratory wheezing

47. A nurse at the weight loss clinic assesses a client who has a large abdomen and a
rounded face. Which additional assessment finding would lead the nurse to suspect that
the client has Cushings syndrome rather than obesity?

abdominal striae and ankle enlargement

large thighs and upper arms

posterior neck fat pad and thin extremities

pendulous abdomen and large hips

48. A newly admitted client is diagnosed with Hodgkins disease undergoes an excisional
cervical lymph node biopsy under local anesthesia. What does the nurse assess first after
the procedure?

Incision site


Level of consciousness

Vital sign

49. A homeless individual is brought to the Emergency Room after having been out in
subfreezing temperatures for three to four days. The toes of the patient's right foot
appear hard and cold with mottling, and are unresponsive to touch. Which of the
following would NOT be included in the initial management of this patient by the
Emergency Room nurse?

Place sterile gauze between the affected digits

Wrap the affected extremity in a blanket and apply moist heat

Rewarm the extremity with controlled and rapid rewarming until the injured part


Elevate the affected extremity

50. Which type of jaundice in adults is the result of increased destruction of red blood cells?





51. Abu Salem is a 46 year-old radio technician who is admitted because of mild chest pain.
He is 5 feet, 8 inches tall and weighs 190 pounds. He is diagnosed with a myocardial
infarct. Morphine sulfate, Diazepam (Valium) and Lidocaine are prescribed. The
physician orders 8 mg of Morphine Sulfate to be given IV. The vial on hand is labeled 1
ml/ 10 mg. The nurse should administer:

12 minims

8 minims

15 minims

10 minims

52. Which of the following stage the carcinogen is irreversible?


Initiation stage


Progression stage
Promotion stage

Regression stage

53. The physician orders non-weight bearing with crutches for Joy, who had surgery for a
fractured hip. The most important activity to facilitate walking with crutches before
ambulation begun is:

Using the trapeze frequently for pull-ups to strengthen the biceps muscles

Sitting up at the edge of the bed to help strengthen back muscles

Doing isometric exercises on the unaffected leg

Exercising the triceps, finger flexors, and elbow extensors

54. Mrs. Mantesh a 78 year old client is admitted with the diagnosis of mild chronic heart
failure. The nurse expects to hear when listening to clients lungs indicative of chronic
heart failure would be:

Friction rubs




55. 14 year old girl has been hospitalized with Sickle Cell Anemia in vasoocclusive crisis.
Which of these nursing diagnoses should receive priority in the nursing plan of care:

Alteration in tissue perfusion

Impaired social interaction


Alteration in body image

56. Osteoporosis is characterized by change in bone density or mass and fragile bones that
lead to fractures. A nurse is conducting a health screening clinic for osteoporosis. The
nurse determines that this client seen in the clinic is at the greatest risk of developing
the disorder.

A sedentary 65 year old female who smokes cigarettes

A 25 year old female who jogs

A 36 year old male who has asthma

A 70 year old male who consumes excess alcohol

57. A nurse is caring for a client who had a closed reduction of a fractured right wrist
followed by the application of a fiberglass cast 12 hours ago. Which finding requires the
nurses immediate attention?

Skin warm to touch and normally colored

Slight swelling of fingers of right hand

Client reports prickling sensation in the right hand

Capillary refill of fingers on right hand is 3 seconds

58. Nurse Trish is aware that temporary heterograft (pig skin) is used to treat burns because
this graft will:
Relieve pain and promote rapid epithelialization

Concurrently used with topical antimicrobials

Debride necrotic epithelium

Be sutured in place for better adherence

59. A client with burns on the chest has periodic episodes of dyspnea. The position that
would provide for the greatest respiratory capacity would be the:

Orthopneic position

Supine position

Sims position

Semi-fowlers position

60. The observation that indicates a desired response to thoracostomy drainage of a client
with chest injury is:

Increased respiratory rate

Increased breath sounds

Constant bubbling in the drainage chamber

Crepitus detected on palpation of chest

61. Faida with a history of chronic infection of the urinary system complains of urinary
frequency and burning sensation. To figure out whether the current problem is in renal
origin, the nurse should assess whether the client has discomfort or pain in the

Urinary meatus

Pain in the Labium

Suprapubic area

Right or left costovertebral angle

62. After gastroscopy, an adaptation that indicates major complication would be:

Abdominal distention

Nausea and vomiting

Difficulty in swallowing

Increased GI motility

63. A chest tube with water seal drainage is inserted to a client following a multiple chest
injury. A few hours later, the clients chest tube seems to be obstructed. The most
appropriate nursing action would be to

Milk the tube toward the collection container as ordered

Arrange for a stat Chest x-ray film.

Prepare for chest tube removal

Clamp the tube immediately

64. Nurse Maureen is aware that a client who has been diagnosed with chronic renal failure
recognizes an adequate amount of high-biologic-value protein when the food the client
selected from the menu was:
Cottage cheese

Raw carrots

Apple juice

Whole wheat bread

65. An early finding in the EKG of a client with an infarcted myocardium would be:

Elevated ST segments

Disappearance of Q waves

Absence of P wave

Flattened T waves

66. A 57 year-old male client has hemoglobin of 10 mg/dl and a hematocrit of 32%. What
would be the most appropriate follow-up by the home care nurse?

Tell the client to schedule an appointment with a hematologist

Tell the client to call an ambulance and go to the emergency department


Schedule a repeat Hemoglobin and Hematocrit in 1 month

Ask the client if he has noticed any bleeding or dark stools

67. A nurse prepares discharge instructions for a patient with chronic syndrome of
inappropriate antidiuretic hormone (SIADH). Which statement indicates that the patient
understands these instructions?

I will use a refractometer to check the specific gravity of my urine. If the result

gradually rises, I will consult my physician.


I will weigh everyday and I will log it in a notebook. I will call my physician

whenever I gain 2 lbs or more in a day without changing my eating habits.


Ill check my pulse every morning and will contact my doctor if its rapid or


I have to avoid too much sodium intake. I will read all food labels to make sure I

dont get too much of it in my diet.

68. Which client is at highest risk for developing a pressure ulcer?

23 year-old in traction for fractured femur

72 year-old with peripheral vascular disease, who is unable to walk without


30 year-old who is comatose following a ruptured aneurysm0

75 year-old with left sided paresthesia and is incontinent of urine and stool

69. A client is prescribed an inhaler. How should the nurse instruct the client to breathe in
the medication?

As quickly as possible

Deeply for 3-4 seconds

As slowly as possible

Until hearing whistling by the spacer
70. A chemotherapeutic agent 5FU is ordered as an adjunct measure to surgery. Which of
the ff. statements about chemotherapy is true?

it affects both normal and tumor cells

it is a local treatment affecting only tumor cells

it has been proven as a complete cure for cancer

it is often used as a palliative measure

71. Mr. Dibagulun is admitted to the hospital with a diagnosis of Left-sided CHF. In the
assessment, the nurse should expect to find:

Extensive peripheral edema

Crushing chest pain

Jugular vein distention

Dyspnea on exertion

72. The nurse is assessing an infant with developmental dysplasia of the hip. Which finding
would the nurse anticipate?

Limited adduction

Symmetrical gluteal folds

Unequal leg length

Diminished femoral pulses

73. Most skin conditions related to HIV disease may be helped primarily by:

improvement of the patient's nutritional status.

highly active antiretroviral therapy (HAART).

low potency topical corticosteroid therapy.

symptomatic therapies

74. A client experiences post partum hemorrhage eight hours after the birth of twins.
Following administration of IV fluids and 500 ml of whole blood, her hemoglobin and
hematocrit are within normal limits. She asks the nurse whether she should continue to
breast feed the infants. Which of the following is based on sound rationale?

"Breastfeeding twins will take too much energy after the hemorrhage."

"Lactation should be delayed until the "real milk" is secreted."

"Nursing will help contract the uterus and reduce your risk of bleeding."

"The blood transfusion may increase the risks to you and the babies.

75. A client is for discharge post TURP. What is the most important teaching a nurse should

Instruct the client to massage the bladder with fist in a rolling motion during


Report signs of foul odor urine, difficulty of starting urination and fever.


Instruct the client to perform perennial exercise by contracting and relaxing the

76. Which of the following is a characteristic sign of SLE?

Rash on the face across the bridge of the nose and cheeks





Elevated rbc count

77. A child is scheduled for tonsillectomy. Which of the following presents the highest risk
of aspiration during surgery?

Difficulty swallowing


Presence of loose teeth


Bleeding during surgery


Exudate in the throat area

78. The chief clinical manifestation that the nurse would expect in the early stages of
cataract formation is:

Eye pain


Floating spots


Blurred vision



80. The nurse is performing an admission assessment on a client with bladder CA. which of
the following would the nurse most likely to expect?








81. A client is admitted to the hospital and has a diagnosis of early stage of CRF. Which of
the following does the nurse expect to note on assessment?








82. A client has developed atrial fibrillation with a ventricular rate of 150 per minute. The
nurse assesses the client for
a. Hypotension and dizziness
b. Nausea and vomiting
c. Hypertension and headache
d. Flat neck veins
2. When assessing a client with ulcerative colitis, which of the following findings would the
nurse report to the physician?
a. Bloody diarrhea
b. Hypotension
c. A hemoglobin level of 12 mg/dL
d. Rebound tenderness
3. Which of the following is a characteristic sign of Lyme Disease Stage I?
a. Signs of neurological disorders
b. Enlarged and inflamed joints

c. Arthalgias
d. Flu-like symptoms
4. Which of the following is not a sign of testicular cancer?
a. Painless testicular swelling
b. Heavy sensation in the scrotum
c. Alopecia
d. Back pain
5. Which of the following data is a sign of paralytic ileus in a patient with acute pancreatitis
and a history of alcoholism?
a. Firm, nontender mass palpable at the lower right costa margin
b. Severe constant pain with rapid onset
c. Inability to pass flatus
d. Loss of anal sphincter control
6. A client is receiving external radiation to the neck for cancer of the larynx. The most
likely side effect to be expected is
a. Constipation
b. Dyspnea
c. Sore throat
d. Diarrhea
7. The client has experienced pulmonary embolism. The nurse assesses for which of the
following symptoms most commonly reported?
a. Dyspnea noted when deep breaths are taken
b. Hot, flushed feeling
c. Chest pain that occurs suddenly
d. Sudden chills and fevers
The nurse is caring for an elderly client with a suspected diagnosis of pneumonia who has just been admitted to the hospital. The
client is slightly confused and is experiencing difficulty breathing. Which activities would be appropriate for the nurse to delegate to
the unlicensed assistant? Select all that apply.
A. Obtaining vital signs
B. Initiating oxygen therapy as needed
C. Applying anti-embolic stockings
D. Assessing the clients chief complaint
A nursing assistant is assigned to care for a client with hemiparesis of the right arm and leg. With regards to morning care, the nurse
instructs the nursing assistant to place personal articles
A. Within the clients reach on the left side.
B. Within the clients reach on the right side.
C. Just out of the clients reach on the right side.
D. Just out of the clients reach on the left side.
Glycosylated hemoglobin of a diabetic client is 4%. What is the nurses correct interpretation?
A. Good control
B. Poor control

C. Fair control
D. Needs further test
For a client placed in Bucks traction, the nurse can provide for countertraction to reduce shear and friction by
A. Providing an overhead trapeze
B. Using a foot board
C. Slightly elevating the head of the bed
D. Slightly elevating the foot of the bed
A patient with tuberculosis is scheduled for chest x-ray. What will the nurse do?
A. Request a portable x-ray to be brought to the patients room
B. Wear a particulate mask when transporting the patient to the x-ray room
C. Bring the patient to the x-ray room when there is fewer crowds in the hallway
D. Ask the patient to wear surgical mask when being transported to the x-ray room.
A nurse is conducting a health teaching for a client who is about to have an inguinal hernia repair (herniorraphy) tomorrow. The
nurse includes all of the following teaching except:
A. Doing lifting works at home 3 weeks after the surgery.
B. Applying ice pack to scrotal area to relieve edema.
C. Wearing scrotal support while ambulating
D. Increasing fiber in the diet to prevent constipation
Rationale: A.
A nurse obtains an order form the physician to restrain a client. The nurse instructs the nursing assistant to apply restraints to the
client. Which of the following observations indicate improper understanding of the nursing assistant in the use of restrains? Select
all that apply.
A. Removing restraints fro 10m minutes every 2 hours for range-of-motion exercises.
B. Restrain straps are safely secured in the side rails
C. The nursing assistant uses safety knot in securing the restrain straps in the bed frame.
D. Allowing enough space between the restrains and skin for movement.
Which of the following would alert the nurse to the potential for delirium tremors in a client undergoing alcohol withdrawal?
A. Ataxia, hunger, hypotension
B. Muscular rigidity, stupor, agitation
C. Hallucinations, hypertension, changes in the level of consciousness
D. Coarse hand tremors, hypotension, agitation
. A client with a diagnosis of peptic ulcer disease ask the nurse about what causes the disease to develop. The nurses appropriately
respond, that according to research, many peptic ulcers are result of which of the following?
A. Diets high in cholesterol
B. Family history of the disease
C. Stress
D. Helicobacter pylori infection
The position of the client for colonoscopy is
A. Prone
B. Right lateral
C. lying on the left side with knees drawn to the chest up
D. Left Sims position
Being weaned from TPN, the client is expected to begin taking solid food today. The ongoing solution rate is has been 100 mL/hour.
A nurse anticipates that which of the following orders regarding the TPN solution will accompany the diet order?
A. Discontinue the TPN.
B. Continue current infusion rate orders for TPN.
C. Decrease TPN rate to 50 mL/hr.
D. Hang 1 L 0.9% normal saline.
A client is receiving TPN in the home setting gained 5 lb weight in a week. The nurse next assesses the client to detect the presence
of which of the following?
A. Crackles on auscultation of the lungs
B. Thirst
C. Decreased blood pressure
D. Polyuria
The nurse after changing the IV bottle observes that the patient exhibits dyspnea. What will the nurse do first?

A. Call the physician

B. Put on lateral side and lower down the head
C. Stop the IV
D. Take the vital signs and call the supervisor
A client with cirrhosis of the liver is scheduled for a liver biopsy. How will the nurse position the client after the procedure?
A. Trendelenburg position
B. Right side lying
C. Semi-Fowlers
A 50-year-old client is receiving radiation therapy in the chest wall for breast cancer. She calls her health care provider and report
that she has pain while swallowing and burning and tightness in her chest. Which of the following complications of radiation
therapy is most likely responsible for her symptoms?
A. Hiatal hernia
B. Stomatitis
C. Radiation enteritis
D. Esophagitis
A pregnant client has just given birth following a cesareanm delivery. While the client was transported to the recovery room, the
nurse assesses the client and suspects the client of having pulmonary embolism, if which of the following clinical manifestation is
A. Bradypnea
B. Bradycardia
C. Dyspnea
D. Decreased respirations