PRACTICE TEST QUESTIONS

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Question Number 1 of 25
The nurse assesses several post partum women in the clinic. Which of
the following women is at highest risk for puerperal infection?

The correct response is "C".

12 hours post partum, temperature of 100.4 degrees Fahrenheit
A)
since delivery
2 days post partum, temperature of 101.2 degrees Farenheit
B)
this morning
3 days post partum, temperature of 100.8 degrees Fahrenheit
C)
the past 2 days
4 days post partum, temperature of 100 degrees Fahrenheit
D)
since delivery
Your response was "B".

The correct answer is C: 3 days post partum, temperature of 100.8

degrees Fahrenheit the past 2 days

A temperature of 100.4 degrees Fahrenheit or higher on 2 successive

days, not counting the first 24 hours after birth, constitutes a post
partum infection.

Question Number 2 of 25
A client is placed on sulfamethoxazole-trimethoprim (Bactrim) for a
recurrent urinary tract infection. Which of the following is appropriate
reinforcement of information by the nurse?

The correct response is "A".

A) "Drink at least 8 glasses of water a day."
B) "Be sure to take the medication with food."
C) "It is safe to take with oral contraceptives."
D) "Stop the medication after 5 days."
Your response was "A".

The correct answer is A: "Drink at least 8 glasses of water a day."

Bactrim is a highly insoluble drug and requires a large volume of fluid

intake. Taking with food is not necessary. Options 3 and 4 are
incorrect instructions with use of bactrim

Question Number 3 of 25
A client is 2 days post operative. The vital signs are: BP - 120/70, HR -
110, RR - 26, and Temperature - 100.4 degrees Fahrenheit (38
degrees Celsius). The client suddenly becomes profoundly short of
breath, skin color is gray. Which assessment would have alerted the
nurse first to the client's change in condition?

The correct response is "B".

A) Heart rate
B) Respiratory rate
C) Blood pressure
D) Temperature
Your response was "C".

The correct answer is B: Respiratory rate

Tachypnea is one of the first clues that the client is not oxygenating
appropriately. The compensatory mechanism for decreased
oxygenation is increased respiratory rate.

Question Number 4 of 25
A client calls the evening health clinic to state “I know I have a
severely low sugar since the Lantus insulin was given 3 hours ago and
it peaks in 2 hours.” What should be the nurse’s initial response to
the client?

The correct response is "B".

A) What else do you know about this type of insulin?
B) What are you feeling at this moment?
C) Have you eaten anything today?
D) Are you taking any other insulin or medication?
Your response was "B".

The correct answer is B: What are you feeling at this moment? When a
client has changed from stable to unstable the initial response is to do
further assessment of the client.

Question Number 5 of 25
The nurse is caring for a client several days following a cerebral
vascular accident. Coumadin (warfarin) has been prescribed. Today's
prothrombin level is 40 (normal range 10-14). Which of the following
is a priority assessment?

The correct response is "A".

A) Neurological signs
 B) Lung sounds
C) Homan's sign
D) Gum bleeding
Your response was "B". The correct answer is A: Neurological signs
Question Number 6 of 25
If a very active two year-old client pulls his tunneled central venous
catheter out, what initial nursing action is appropriate?

The correct response is "C".

A) Obtain emergency equipment
B) Assess heart rate, rhythm and all pulses
C) Apply pressure to the vessel insertion site
D) Use cold packs at the exit incision site
Your response was "C".

The correct answer is C: Apply pressure to the vessel insertion site If a

central venous catheter is accidentally removed, pressure should be
applied to the vein entry site assessments are a priority in this post-
CVA client

Question Number 8 of 25
Before administering a feeding through a gastrostomy tube, what is
the priority nursing assessment?

The correct response is "D".

A) Measure the vital signs
B) Palpate the abdomen
C) Assess for breath sounds
D) Verify tube patency
Your response was "D".

The correct answer is D: Verify tube patency Tube patency should be

checked prior to all feedings. The feeding should not be attempted if
the tube is not patent

Question Number 9 of 25
During a fluid exchange for the client who is 48 hours post insertion of
the abdominal Tenckhoff catheter for peritoneal dialysis, the nurse
knows that the appearance of which of the following needs to be
reported to the health care provider immediately?
The correct response is "D".
A) Slight pink - tinged drainage
 B) Abdominal discomfort
C) Muscle weakness
D) Cloudy drainage
Your response was "C".

The correct answer is D: Cloudy drainage Cloudy drainage is a sign of

infection that can lead to peritonitis (inflammation of the peritoneum).
Other options are expected side effects of peritoneal dialysis.

Question Number 10 of 25
A client has a serum glucose of 385 mg/dl. Which of these orders
would the nurse question first?
The correct response is "C".
A) repeat glycohemoglobin in 24 hours
B) document accuchecks, intake and output every 4 hours
C) humulin N 20 units IV push
D) IV fluids of 0.9% normal saline at 125 ml per hour
Your response was "C".

The correct answer is C: humulin N 20 units IV push Regular insulin is

the only insulin that can be given by the intravenous route. This is the
initial order to question. Another order to question is option 1 although
it is not a priority since the client would not be harmed by this action.
This lab test gives the average glucose on the hemoglobin molecule for
the past 2 to 3 months. There would be no need to repeat it at this
time. A fasting glucose in the morning would be more appropriate to
obtain. The other orders are within expected actions in this situation.

Question Number 11 of 25
The nurse is caring for a client who is receiving total parenteral
nutrition (hyperalimentation and lipids). What is the priority nursing
action on every 8 hour shift?

The correct response is "C".

A) Monitor blood pressure, temperature and weight
B) Change the tubing under sterile conditions
C) Check urine glucose, acetone and specific gravity
D) Adjust the infusion rate to provide for total volume
Your response was "B".

The correct answer is C: Check urine glucose, acetone and specific

gravity
Because of the high dextrose and protein content in parenteral
nutrition, the nurse should assess the urine at least every 8 hours

Question Number 12 of 25
The nurse is caring for a client on complete bed rest. Which action by
the nurse is most important in preventing the formation of deep vein
thrombosis?

The correct response is "D".

A) Elevate the foot of the bed
B) Apply knee high support stockings
C) Encourage passive exercises
D) Prevent pressure at back of knees
Your response was "C".

The correct answer is D: Prevent pressure at back of knees

Preventing popliteal pressure will prevent venous stasis and possibly

deep vein thrombosis.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards

and Practice. (2nd ed). Clinton Park, New York: Delmar

Question Number 13 of 25
What must the nurse emphasize when teaching a client with
depression about a new prescription for nortriptyline (Pamelor)?

The correct response is "B".

A) Symptom relief occurs in a few days
B) Alcohol use is to be avoided
C) Medication must be stored in the refrigerator
D) Episodes of diarrhea can be expected
Your response was "B".

The correct answer is B: Alcohol use is to be avoided

Alcohol potentiates the action of tricyclic antidepressants

Question Number 14 of 25
A client returns from the operating room after a right orchiectomy. For
the immediate post operative period the nursing priority would be to

The correct response is "B".

A) Maintain fluid and electrolyte balance
 B) Manage post operative pain
C) Ambulate the client within 1 hour of surgery
D) Control bladder spasms
Your response was "A".

The correct answer is B: Manage post operative pain

Due to the location of the incision, pain management is the priority.

Bladder spasms are more related to prostate surgery

Question Number 15 of 25
A client is waiting to have an intravenous pyelogram (IVP). The most
important factor to be obtained by the nurse prior to the procedure is

The correct response is "B".

A) time to the client's last meal
B) the client's allergy history
C) assessment of the peripheral pulses
D) results of the blood coagulation studies
Your response was "B".

The correct answer is B: the client''s allergy history

Intravenous Pyelogram is a dye study that uses an iodine-based

contract. Therefore, the study is contraindicated in clients with allergy
to iodine.

Question Number 16 of 25
A client with a fracture of the radius had a plaster cast applied 2 days
ago. The client complains of constant pain and swelling of the fingers.
The first action of the nurse should be

The correct response is "C".

A) Elevate the arm no higher than heart level
B) Remove the cast
C) Assess capillary refill of the exposed hand and fingers
D) Apply a warm soak to the hand
Your response was "C".

The correct answer is C: Assess capillary refill of the exposed hand and
fingers
A deterioration in neurovascular status indicates the development of
compartment syndrome (elevated tissue pressure within a confined
area) which requires immediate pressure reducing interventions

Question Number 17 of 25
When caring for a client with urinary incontinence, which content
should be reinforced by the nurse?

The correct response is "D".

A) Hold the urine to increase bladder capacity
B) Avoid eating foods high in sodium
C) Restrict fluid to prevent elimination accidents
D) Avoid taking antihistamines
Your response was "D".

The correct answer is D: Avoid taking antihistamines

Antihistamines can aggravate urinary incontinence and should be

avoided in clients with urinary incontinence. Holding the urine,
avoiding sodium, and restricting fluids have not been shown to reduce
urinary incontinence.

Question Number 18 of 25
A client arrives in the emergency department after a radiologic
accident at a local factory. The next action of the nurse would be to

The correct response is "B".

A) begin decontamination procedures for the client
B) ensure physiologic stability of the client
C) wrap the client in blankets to minimize staff contamination
D) double bag the client’s contaminated clothing
Your response was "D".

The correct answer is B: ensure physiologic stability of the client

The nurse must initially assist in stabilizing the patient prior to

performing the other tasks related to radiologic contamination.

Question Number 19 of 25
A client has been on antibiotics for 72 hours for cystitis. Which report
from the client requires priority attention by the nurse?

The correct response is "C".

 A) Foul smelling urine
B) Burning on urination
C) Elevated temperature
D) Nausea and anorexia
Your response was "A".

The correct answer is C: Elevated temperature

Elevated temperature after 72 hours on an antibiotic indicates the

antibiotic is not effective in eradicating the offending organism. The
provider should be informed immediately so that a more effective
medication can be prescribed, and complications such as
pyelonephritis are prevented. Options 1 and 2 are expected with
cystitis. Option 4 may be related to the antibiotics as a side effect and
should also be reported to the provider

Question Number 20 of 25
The nurse is caring for a school aged child with a diagnosis of
secondary hyperparathyroidism following treatment for chronic renal
disease. Which of the following lab data should receive priority
attention?

The correct response is "A".

A) Calcium and phosphorus levels
B) Blood sugar
C) Urine specific gravity
D) Blood urea nitrogen
Your response was "B".

The correct answer is A: Calcium and phosphorus levels

Calcium and phosphorous levels will be elevated until the client is

stabilized.

Question Number 21 of 25
The nurse is caring for a pregnant woman with pregnancy induced
hypertension receiving magnesium sulfate intravenously. In assessing
the client, it is noted that respirations are 12, pulse and blood pressure
have dropped significantly, and 8 hour output is 200 ml. What should
the nurse do first?

The correct response is "C".

A) Administer calcium gluconate
B) Call the health care provider immediately
 C) Discontinue the magnesium sulfate
D) Perform additional assessments
Your response was "C".

The correct answer is C: Discontinue the magnesium sulfate

The assessments strongly suggest magnesium sulfate toxicity. The

nurse must discontinue the IV immediately and take measures to
ensure the safety of the client.

Question Number 22 of 25
The nurse is caring for a client with a vascular access for hemodialysis.
Which of these findings necessitates immediate action by the nurse?

The correct response is "D".

A) Pruritic rash
B) Dry, hacking cough
C) Chronic fatigue
D) Elevated temperature
Your response was "A".

The correct answer is D: Elevated temperature

It is a priority to report this finding since clients on hemodialysis are

prone to infection and the first sign is an elevated temperature. Other
findings should be reported to the care provider as well

Question Number 23 of 25
The nurse must know that the most accurate oxygen delivery system
available is

The correct response is "A".

A) The venturi mask
B) Nasal cannula
C) Partial non-rebreather mask
D) Simple face mask
Your response was "A".

The correct answer is A: The venturi mask

The most accurate way to deliver oxygen to the client is through a

venturi system such as the Venti Mask. The Venti Mask is a high flow
device that entrains room air into a reservoir device on the mask and
mixes the room air with 100% oxygen. The size of the opening to the
reservoir determines the concentration of oxygen. The client’s
respiratory rate and respiratory pattern do not affect the concentration
of oxygen delivered. The maximum amount of oxygen that can be
delivered by this system is 55%.

Question Number 24 of 25
The nurse is caring for a client with a chest tube. On the second
postoperative day, the chest tube accidentally disconnects from the
drainage tube. The first action the nurse should take is

The correct response is "D".

A) Reconnect the tube
B) Raise the collection chamber above the client's chest
C) Call the health care provider
D) Clamp the chest tube
Your response was "A".

The correct answer is D: Clamp the chest tube

Immediate steps should be taken to prevent air from entering the

chest cavity. Lung collapse may occur if air enters the chest cavity.
Clamping the tube close to the client’s chest is the first action. Health
care provider notification follows this action

Question Number 25 of 25
The nurse is responsible for decisions regarding client room
assignments. Which possible roommate would be most appropriate for
a 3 year-old child with minimal change nephrotic syndrome?

The correct response is "C".

A) 2 year-old with respiratory infection
B) 3 year-old fracture whose sibling has chickenpox
C) 4 year-old with bilateral inguinal hernia repair
D) 6 year-old with a sickle cell anemia crisis
Your response was "C".

The correct answer is C: 4 year-old with bilateral inguinal hernia repair

The nurse must know that children with nephrotic syndrome are at
high risk for development of infections as a result of the standard use
of immunosuppressant therapy as well as from the accumulation of
fluid (edema). Therefore, these children must be protected from
sources of possible infection. The sickle cell crisis has potential to have
occurred from an infectious process