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1. The nurse would evaluate that the client understands his home care
instructions after scleral buckling for a detached retina if he says his
activity should include:
a. Avoiding abrupt movements of the head
b. Exercising the eye muscles each day
c. Turning the entire head rather than just the eyes for sight
d. Avoiding activities requiring good depth perception
2. Lomotil has been prescribed to treat a client’s diarrhea. The nurse should
teach the client to report which of the following common side effects?
a. Urinary retention
b. Diaphoresis
c. Hypotension
d. Lethargy
5. For a neurologically injured client, the nurse would best assess motor
strength by:
a. Comparing equality of hand grasps
b. Observing spontaneous movements
c. Observing the client feed himself
d. Asking him to signal if he feels pressure applied to his feet
6. Morphine 8 mg IM has been ordered for a client. The ampule label reads 15
mg/mL. How many milliliters will the nurse give?
a. 0.45 mL
b. 0.53 mL
c. 0.66 mL
d. 0.75 mL
7. The correct procedure for auscultating the client’s abdomen for bowel
sounds would include:
a. Palpating the abdomen first to determine correct stethoscope
placement
b. Encouraging the client to cough to stimulate movement of fluid and
air through the abdomen
c. Placing the client on the left side to aid auscultation
d. Listening for 5minutes in all four quadrants to confirm
absence of bowel sound
12. Which of the following lab results would be unexpected in a client with
chronic renal failure?
a. Serum potassium 6.0 mEq/L
b. Serum creatinine 9 mg/dL
c. BUN 15 mg/dL
d. Serum phosphate 5.2 mg/dL.
15. The nurse notes that the client’s urinary appliance contains yellow urine
with large amounts of mucus. How would the nurse best interpret these
data?
a. The client is developing an infection of the urinary tract
b. The mucus is caused by elevated levels of glucose in the urine
c. These findings are normal for a client with an ileal conduit
d. There is irritation of the stoma
16. Which of the following assessments would be important for the nurse to
make to determine whether or not a client is recovering as expected from
spinal anesthesia?
a. Level of consciousness
b. Rate and depth of respirations
c. Rate of capillary refill in the toes
d. Degree of response to pinpricks in the legs and toes
18. The nurse has instructed the client about the correct positioning of his
leg and hip following hip replacement surgery. Which of the following
statements indicate that the client has understood these instructions?
a. I may cross my legs as long as I keep my knees extended
b. I should avoid bending over to tie my shoes
c. I can sit in any chair that I find comfortable
d. I should avoid any unnecessary walking for about 3 months after my
surgery
19. Clients with diabetes mellitus require frequent vision assessment. The
nurse should instruct the client about which of the following eye problems
most likely to be associated with diabetes mellitus?
a. Cataracts
b. Retinopathy
c. Astigmatism
d. Glaucoma
20. An autograft is taken from the client’s left leg. The nurse should care
for the donor site by:
a. Covering it with an occlusive dry dressing
b. Keeping the site clean and dry
c. Applying a pressure dressing
d. Wrapping the extremity with an elastic bandage
25. Which of the following observations should the postanesthesia care unit
(PACU) nurse plan to make first when the client who has had a modified
radical mastectomy returns from the operating room?
a. Obtaining and recording vital signs
b. Observing that drainage tubes are patent and functioning
c. Ensuring that the client’s airway is free of obstruction
d. Checking the client’s dressings for drainage
26. The classic signs and symptoms of rheumatoid arthritis include which of
the following?
a. Pain on weight-bearing, rash and low-grade fever
b. Joint swelling, joint stiffness in the morning and bilateral joint
movement
c. Crepitus, development of Heberden’s nodes and anemia
d. Fatigue, leucopenia and joint pain
27. Nursing measures for the client who has had an MI include helping the
client to avoid activity that results in Valsalva’s maneuver. Valsalva’s
maneuver may cause cardiac dysrhythmias, increased venous pressure,
increased intrathoracic pressure and thrombi dislodgement. Which of the
following actions would help prevent Valsalva’s maneuver? Have the client:
a. Assume a side-lying position
b. Clench her teeth while moving in bed
c. Drink fluids through a straw
d. Avoid holding her breath during activity
28. A client is scheduled for radical neck surgery and a total laryngectomy.
During the preoperative teaching, the nurse should prepare the client for
which of the following postoperative possibilities?
a. Endotracheal intubation
b. Insertion of laryngectomy tube
c. Immediate speech therapy
d. Gastrostomy tube
30. Which statement by the client with rheumatoid arthritis would indicate
that she needs additional teaching to safely receive the maximum benefit
of her aspirin therapy?
a. I always take aspirin with food to protect my stomach
b. Once I learned to take aspirin with meals, I was able to start using
the inexpensive generic brand
c. I always watch for bleeding gums or blood in my stool
d. I try to take aspirin only on days when the pain seems
particularly bad
31. A client has stress incontinence has been given a pamphlet that
describes Kegel exercises. Which of the following statements indicates to
the nurse that the client has understood the instructions contained in the
pamphlet?
a. I should perform these exercises every evening
b. It will probably take a year before the exercises are effective
c. I can do these exercises sitting up, lying down or standing
d. I need to tighten my abdominal muscles to do these exercises
correctly
33. Oxtriphylline (Choledyl SA) 0.2 g has been ordered. Available tablets
are 100mg. How many tablets should be given?
a. 0.5 tablets
b. 2.0 tablets
c. 2.5 tablets
d. 5.0 tablets
35. Which of the following nutrients provides a little over half of the energy
needed during sleep?
a. Protein
b. Carbohydrate
c. Fat
d. Water
36. An anticipated outcome for the client after cataract removal surgery
would include which of the following?
a. The client states her vision is clear
b. The client states her infection is under control
c. The client describes methods to prevent an increase in
intraocular pressure
d. The client states she is able to administer parenteral pain medication
38. The nurse notes the following assessment findings regarding the client’s
peripheral vascular status: cramping leg pain relieved by rest; cool, pale
feet; and delayed capillary refilling. Based on these data, the nurse would
make a nursing diagnosis of:
a. Impaired skin integrity
b. Impaired gas exchange
c. Ineffective peripheral tissue perfusion
d. Impaired physical mobility
39. The client with urinary tract infection is given a prescription for
trimethoprim (Bactrim-DS) for her infection. Which of the following
statements would indicate that she understands the principles of antibiotic
therapy?
a. I’ll take the pills until I feel better and keep the rest for recurrences
b. I’ll take all the pills then return to my doctor
c. I’ll take the pills until the symptoms go away then reduce the dose to
one pill a day
d. I’ll take all the pills then have the prescription renewed once
40. Which of the following clients would the nurse expect to be at highest
risk for developing a urinary tract infection?
a. Woman who has delivered two children vaginally
b. Man with an indwelling urinary catheter for incontinence
c. Man with a past medical history of renal calculi
d. Woman with well-controlled diabetes mellitus
41. When bandaging the burned client’s hand, the nurse should make
certain that:
a. The bandage is free of elastic
b. The hand and finger surfaces do not touch
c. The hand and fingers are not elevated above heart level
d. The bandage material is moistened with sterile normal saline solution
42. The nurse is caring for a client who has a history of aplastic anemia.
Which of the following data from the nursing history indicates that the
anemia is not being managed effectively?
a. Pallor of skin and mucous membranes
b. Heart rate of 68 bpm, bounding pulse
c. Blood pressure of 146/90 mm Hg
d. Poor skin turgor
43. A client is learning about caring for her ileostomy. Which of the
following statements would indicate that she understands how to care for
her ileostomy pouch?
a. I’ll empty my pouch when it’s about one-third full
b. I can take my pouch off at night
c. I should change my pouch immediately after lunch
d. I must apply a new pouch system every day
44. A client’s laboratory tests indicate that the client has hypocalcemia.
Which of the following symptoms should the nurse look for in the client?
a. Flushed skin
b. Depressed reflexes
c. Tingling in extremities
d. Diarrhea
45. Which of the following symptoms would the nurse most likely observe
in a client with cholecystitis from cholelithiasis?
a. Black stools
b. Nausea after ingestion of high fat foods
c. Elevated temperature of 103 F (39.4 C)
d. Decreased WBC count
46. Pain control is an important nursing goal for the client with pancreatitis.
Which of the following medications would the nurse plan to administer in
this situation?
a. Meperidine hydrochloride (Demerol)
b. Cimetidine (Tagamet)
c. Morphine sulfate
d. Codeine sulfate
47. A client is recovering from a gastric resection for peptic ulcer disease.
Which of the following outcomes indicates that the goal of adequate
nutritional intake is being achieved 3 weeks following surgery?
a. Increases food intake and tolerance gradually
b. Experiences occasional episodes of nausea and vomiting
c. Drinks 2000 mL/day of water
d. Experiences a rapid weight gain within 1 week
48. What would be the most important nursing intervention in caring for
the client’s residual limb during the first 24 hrs after amputation of the left
leg?
a. Keeping the residual limb flat on the bed
b. Abducting the residual limb on a scheduled basis
c. Applying traction to the residual limb
d. Elevating the residual limb on a pillow
49. After the client returns from surgery for a deviated nasal septum, the
nurse would anticipate placing her in what position?
a. Supine
b. Left side-lying
c. Semi-Fowler’s
d. Reverse Trendelenburg’s
50. While suctioning a client’s laryngectomy tube, the nurse insert the
catheter:
a. About 1-2 inches
b. As the client exhales
c. Until resistance is met, then withdraw it 1-2 cm
d. Until the client begins coughing