1. A client as an obsessive-compulsive disorder manifested by the compulsion of handwashing.

The nurse knows

that which of the following best describes the clients need for the repetitive acts of handwashing?
a. Handwashing represents an attempt to manipulate the environment to make it more comfortable.
b. Handwashing externalizes the anxiety from a source within the bidy to an acceptable substitute outside
the body.
c. Handwashing assists the client to avoid undesirable thoughts and maintain some control over guilt and
anxiety.
d. Handwashing helps to maintain the client in an active state to resist the effects of depression.
2. Following the vaginal delivery of an 11-pound baby, the nurse encourages the mother to breastfeed her
newborn. What is the primary purpose of this action?
a. To initiate the secretion of colostrum
b. To prevent neonatal hyperglycemia
c. To facilitate maternal-newborn interaction.
d. To stimulate the uterus to contract.
3. Client is admitted for a series of tests to verify the diagnosis of Cushings syndrome. Which of the following
assessment findings, if observed by the nurse, would support this diagnosis?
a. Buffalo hump, hyperglycemia, and hypernatremia
b. Nervousness, tachycardia, and intolerance to heat
c. Lethargy, weight gain and intolerance to cold
d. Irritability, moon face and dry skin
4. The nurse is caring for a child with acute renal failure who is in the intensive care unit. Which assessment
finding would indicate a sign of tonsialemia?
a. Seizure
b. ECG changes
c. Dyspnea
d. Oliguria
5. In planning care for a 7-year-old client with Graves disease, what should the nurse do?
a. Encourage frequent rest periods
b. Encourage strenuous physical activity
c. Administer thyroid hormone replacement daily
d. Encourage a decrease caloric intake
6. The nurse recognizes which of the following as early sign of lithium toxicity?
a. Restlessness, shuffling gait, involuntary muscle movements
b. Ataxia, confusion, seizures
c. Fine tremors, nausea, vomiting, diarrhea
d. Elevated white blood cell count, orthostatic hypotension
7. The nurse is preparing to do a shift assessment on a client who was admitted with an upper gastrointestinal
bleed. Which signs and symptoms would indicate active bleeding? (Select all that apply)
a. Blood pressure 80/52 mmHg
b. Stool black and tarry
c. Hemoglobin 18g/dL
d. Hematocrit 32%
e. Heart rate 128 beats/min
f. Respirations 32 and shallow
8. Mr. Rollins is a known alcoholic who is brought to the Emergency Department by the police. He has severe
ascites from his chronic alcoholism and the physician prescribes spironolactone 50mg orally now. The pharmacy
dispenses spironolactone 25mg tablets. How many tablets do you give Mr. Rollins?
a. 2 tablets
b. 0.5 tablet
c. 4 tablets
d. 1 tablet
9. A client is admitted with suspected pneumonia. The chest xray reveals right middle and lower lunch
consolidation. During auscultation of the middle and lower lobes, which finding related to the pulmonary
system would the nurse anticipate?
a. Inspiratory and expiratory wheezing

b. Decreased breath sounds

c. Tympanic hyperresonance
d. Bronchovesicular sounds
10. Prior to electroconvulsive therapy (ECT) treatment, the patient receives an injection of a medication that
reduces secretions and protects against vagal bradycardia. Which medication will you administer?
a. Fluoxetine (Prozac)
b. Diphenhydramine (Bendaryl)
c. Atropine
d. Epinephrine (Adrenalin)
11. Patient
a.
b.
c.
d.

with Alzheimers wandering in the hallway, which of the following should the nurse do?
Place in soft restraints
Place in a restraint chair in the nurse station
Place chemical restraints
Ask relative to stay with the patient

12. Mrs. Robinson is a 38 year old woman being treated on an outpatient basis for depression. Three months ago,
her husband revealed that he was having an affair with her best friend and planned to file for divorce. Three
weeks ago, Mrs. Robinsons 14 year old son (her only child) committed suicide on an inpatient psychiatric
mental health unit.in todays therapy session, Mrs. Robinson reveals to her nurse therapist that she is seriously
contemplating suicide herself. What action should the therapist take?
a. Arrange for voluntary hospitalization, if the patient is willing
b. None, because people who speak of committing suicide seldom do it
c. Arrange for immediate hospitalization
d. Request permission to speak with the husband to suggest marriage counseling
13. A young adult client is scheduled for her first debridement of a second-degree burn of the left arm. It is most
important for the nurse to take which of the following actions?
a. Assemble all necessary supplies and medications
b. Plan adequate time for the dressing change and provide emotional support
c. Prepare the client and family for the pain the client will experience during and after the procedure
d. Limit visitation prior to the procedure to reduce stress
14. The nurse is caring for a 67 years old man following a cardiac catheterization. Two hours after the procedure,
the nurse checks the patients insertion site in the antecubital space, and the patient complains that his hand
is numb. The nurse should:
a. Change the position of his hand
b. Check his grip strength in both hands
c. Notify the physician
d. Instruct the patient to exercise his fingers
15. A client is to receive 1000mL of IV fluid over 10 hours. The IV tubing set calibration is 15gtt/mL.how many
drops per minute would the nurse give?
a. 125gtt/min
b. 115gtt/min
c. 25gtt/min
d. 100gtt/min
16. Which intervention would the nurse anticipate for a patient who is diagnosed with osteitisdeformans (Pagets
disease)?
a. Biphosphate and recommended doses if calcium and vitamin D
b. Calcitonin and vitamin A supplements
c. Estrogen and physical therapy
d. A low-phosphorus and aerobic exercise
17. The nurse has just received report from the previous shift. Which of the following clients should the nurse see
first?
a. A client who is receiving a blood transfusion and complains of a dry mouth
b. A client who is scheduled to receive heparin and PTT is 70 seconds
c. A client who is receiving ciprofloxacin (Cipro) and complains of fine macular rash
d. A client who is receiving IV potassium and complains of burning at the IV site

18. Refer to the following list of drug indications, actions and side effects. Which statement matches with
simvastatin (Zocor)?
a. Lowers LDL level, increase HDL level, and slows progression of coronary artery disease. Adverse effects
may include myopathy, and hepatotoxicity
b. Lowers LDL, triglycerides, and apolipoprotein B levels by blocking absorption in the gastrointestinal
tract. Minimal adverse effects have been identified.
c. Lowers LDL cholesterol and VDL triglyceride levels; raises HDL. May cause severe flushing
d. Reduces VLDL and increases HDL levels. Gastrointestinal disturbances and an increased risk of
gallstones may occur.
19. A client is admitted with irritable bowel syndrome. The nurse would anticipate the clients history to reflect
which of the following?
a. Pattern of alternating diarrhea and constipation
b. Chronic diarrhea stools occurring 10-12 times per day
c. Diarrhea and vomiting with severe abdominal distention
d. Bloody stools with increased cramping after eating
20. The nurse is preparing to do postoperative assessment on a 5 year old child who has undergone tonsillectomy.
During the assessment, the nurse should be alert for bleeding. Which signs and symptoms would indicate active
bleeding? (select all that apply)
a. Drowsiness
b. Dark red vomitus
c. Mouth breathing
d. Frequent swallowing
e. Frequent clearing of throat
21. The nurseis preparing to administer carvedilol (Coreg) to a patient. Which action should the nurse take first?
a. Find the results of the patients last blood pressure measurement
b. Check the patency of the patients IV line
c. Assess the patients current pulse and blood pressure
d. Review the patients urine output as recorded by nurses on the previous shift.
22. Who to
a.
b.
c.
d.

see first?
Post colectomy with abdominal cramping
Patient with post bone marrow transplant with diarrhea
Patient with cast 30 minutes ago with muscle spasm
Patient chemo with n/v

23. A 47 year old woman comes to the outpatient psychiatric clinic for treatment of a fear of heights. The nurse
knows that phobias include:
a. Projection and displacement
b. Sublimation and internalization
c. Rationalization and intellectualization
d. Reaction formation and symbolization
24. When teaching a client with myasthenia gravis about the management of the disease, what advice should the
nurse give to the patient?
a. Prevent structured, active exercises at least twice a week to prevent muscle atrophy
b. Protect extremities from injury due to decreased sensory perception
c. Arrange a routine to accommodate frequent visits to doctors office
d. Perform necessary physically demanding activities in the morning
25. Client with paranoid thinks he is the son of the US president. During interaction, he began to have
hallucinations again, which action should be done by the nurse first?
a. Ignore the hallucinations and proceed with the interaction
b. Recognize the patients anxiety the proceed with the interaction
c. Let the hallucinations be the center or topic of the interaction
d. Ask for help
26. Your patient has been admitted in preterm labor and is receiving magnesium sulfate as a tocolytic. You prepare
her for the common side effects of this medication, which include drowsiness, lethargy, feeling warm and

a.
b.
c.
d.

Palpitations
Muscular weakness
Tremulousness
Tachycardia

27. A client has just been admitted after sustaining a second-degree thermal injury to his right arm. Which of the
following nursing observations is most important to report to the doctor?
a. Pain around the periphery of the injury
b. Gastric pH less than 6.0
c. Increased edema of the right arm
d. An elevated hematocrit
28. Which
a.
b.
c.
d.

drug would the nurse question?

Prozac for client with bulimia
Seroquel for patient with undifferentiated schizophrenia
Olanzapine for OC
Buspar for client with anxiety

29. A patient with Raynauds disease should be taught to avoid which environmental factor?
a. High levels of smog
b. Cold temperature
c. Exposure to secondhand smoke
d. Contact with pesticide
30. Which statement by a 7-year-old client would indicate an understanding of when to take medication (via
inhaler)?
a. After one puff, I can immediately give myself another puff
b. I need to depress the top of the inhaler as I begin to take a breath.
c. When I remove the inhaler, I can exhale through my mouth.
d. I need to inhale the medicine and then hold my breath to the count of 10.
31. To detect diabetic ketoacidosis (DKA), which of following would you test for ketones?
a. Plasma
b. Feces
c. Urine
d. Sputum
32. A client has been diagnosed with metastatic cancer with a poor prognosis. Recently, the client has complained
of increased pain and is less communicative, very irritable, and anorexic. Which of the following nursing goals
should be a priority at this time?
a. Encourage client to talk about the possibility of dying.
b. Provide pain assessment and effective pain management
c. Manage nutrition and hydration
d. Verify that the physician has discussed the prognosis with the family
33. A 60-year old man with a diagnosis of pneumonia is being admitted to the medical/surgical unit. The nurse
should place the patient in a room with which of the following patients?
a. A 20-year-old in traction for multiple fractures of the left lower leg
b. A 35-year-old with recurrent fever of unknown origin
c. A 50-year-old recovering alcoholic with cellulitis of the right foot
d. An 89-year-old with Alzheimers disease awaiting nursing home placement
34. A patient is hospitalized for severe pregnancy-induced hypertension (PIH). Her hematocrit has increased two
points since the previous day. What is the probable cause of this increase?
a. A shift of red blood cells from the fetus
b. A shift of fluid from the vascular compartment
c. Decreased red blood cell destruction by the spleen
d. Increased hematopoiesis in the red bone marrow
35. Lucy is a 34-year-old married woman with chronic low self-esteem. Which action by Lucy demonstrates
assertive behavior and positive interpersonal relationships?

a. Lucy requests that her husband join her weekly sessions to deal with the husbands use of alcohol and
extramarital affair.
b. Lucy cries for 28 minutes of the 30-minute therapy session
c. Lucy says to the nurse, My husbands behavior gives me headaches, so I sleep a lot.
d. Lucy says to the nurse, I am going to make other peoples lives as miserable as mine is.
36. The nurse on a psychiatric unit of the hospital refuses to agree to a 32-year-old patients request to organize a
party on the unit with his friends. The patient becomes angry and uses abusive language with the nurse. Which
of the following statements indicates that the nurse has an understanding of the patients behavior?
a. Allowing the patient to use abusive language will undermine the authority of the nurse.
b. Responding in kind to a patient who uses abusive language will perpetuate the behavior.
c. Abusive language is one the behaviors that is a symptom of the patients illness.
d. The nurse should model acceptable behavior and language for all patients.
37. You are caring for a 7-year-old client with a brain tumor. Which observation would alert you to the possible
development of syndrome of inappropriate antidiuretic hormone secretion (SIADH)?
a. Serum sodium of 130 mEq/L
b. Weight loss
c. Urinary output of 30mL/h
d. Peripheral edema
38. The nurse is preparing a client for a skin biopsy. Which of the following client statements should the nurse
report to the physician?
a. Ive been taking aspirin for my sore knees.
b. Using lotion has helped my dry skin.
c. I went to the tanning salon yesterday.
d. I had a big breakfast this morning.
39. Endoscopic Retrograde Choliangopancreatography (ERCP) SATA
a. Check for gag reflex postprocedure
b. No discomfort post-procedure
c. Anesthesia will be used
d. No special prep needed
e. NPO prior to procedure
f. Will stay in hosp for a few days post op
40. The patient is taking ibandronate (Boniva) for the prevention of osteoporosis. Which statement should be part
of the patient education provided by the nurse?
a. Take the medication with a minimal amount of fluid just before bedtime.
b. Take the drug first thing in the morning with a full glass of milk or juice.
c. Take the medication on a full stomach immediately after meal.
d. Take the medication in the morning with a glass of water and then dont ingest anything for 30
minutes.
41. The nurse has administered sublingual nitroglycerin (Nitrostat) to a client complaining of chest pain. Which of
the following observations is most important for the nurse to report to the next shift?
a. The client indicates the need to use the bathroom.
b. Blood pressure has decreased from 140/80 to 90/60.
c. Respiratory rate has increased from 16 to 24.
d. The client indicates that the chest pain has subsided.
42. In planning care for a client with cirrhosis who was admitted with bleeding esophagealvarices, to which goal
should the nurse assign the highest priority?
a. Maintain fluid volume
b. Relieve clients anxiety
c. Maintain airway patency
d. Control the bleeding
43. A client is admitted to the neurology unit for a myelogram. It would be most important for the nurse to ask
which of the following questions?
a. Do you have any allergies?

b. Have you been drinking lots of fluids?

c. Are you wearing any metal objects?
d. Are you taking medication?
44. A nursing assistant is assigned to constant observation of a suicidal patient, and the nurse overhears the nursing
assistant talking with the patient. Which of the following statements made by the nursing assistant would
require immediate intervention by the nurse?
a. Lets put your clothes in the dresser.
b. Ill stay in the bathroom with you while you take your shower.
c. Youre going to be moved to private room later today.
d. Ill be right back with something for you to eat.
45. A patient diagnosed with angina is instructed to rest when having an episode of chest pain. What is the best
explanation for how rest relieves the pain associated with angina?
a. Increased venous return to the heart decrease myocardial oxygen needs.
b. Coronary arteries constrict and shunt blood to vital areas of the myocardium.
c. A balance between myocardial cellular needs and demand is achieved.
d. Coronary blood vessels dilate and increase myocardial cell perfusion.
46. Twelve hours after a total thyroidectomy, the client develops stridor on exhalation. What is the nurses best
first action?
a. Hyperextend the client's neck.
b. Reassure the client that the voice change is temporary.
c. Call for emergency assistance.
d. Document the finding as the only action.
47. Which of the following is the first nursing action that should be implemented for a 25-year-old woman after a
vaginal delivery?
a. Check the patients lochial flow
b. Palpate the patients fundus
c. Monitor the patients pain
d. Assess the patients level of consciousness
48. The nurse is caring for a client receiving amphotericin B (Fungizone) 1mg in 250cc of 5% dextrose in water IV
over a 2-hour period. The nurse should be most concerned if which of the following was observed?
a. BUN 7.2 mg/dL, creatinine 0.5 mg/dL.
b. BP 90/60, complaints of fever and chills.
c. Complaints of burning on urination, thirst, and dizziness.
d. AST (SGOT) 12 U/L, ALT (SGPT) 14 U/L, total bilirubin 0.2 mg/dL.
49. What equipment would be necessary for the nurse to complete an evaluation of cranial nerve III during a
physical assessment?
a. Tongue depressor
b. A pen light
c. A cotton swab
d. A safety pin
50. A G1P0 30-year-old patient at 38 weeks gestation is admitted with heavy, bright red bleeding. The initial
nursing assessment should include all of the following except?
a. Fetal monitoring
b. Asking about the pain
c. Taking vital signs
d. A vaginal examination
51. A 12-year-old client has a right tibia fracture that is casted. The client needs instruction regarding how to walk
in crutches using a three-point gait prior to be discharged from the Emergency Department. Which instructions
would be included? (SATA)
a. The hands and arms support the bodys weight
b. The body swings through and beyond the crutches
c. The right foot acts like a balance
d. Advance both crutches and swing both feet forward
e. Weight bearing is permitted on the right foot
f. Weight bearing is permitted on the left foot

g. The axillary area supports the body weight

52. Which
a.
b.
c.
d.

patient is robust?
Pulse pressure of 40
BP of 90/60
RR of 8
CVP of 30cmH2O

53. What action should the nurse take when performing intermittent nasogastric (NG) feedings in a client? SATA
a. Keep the head of the bed elevated at 15 degrees
b. Irrigate the NG tube prior to initiating feeding
c. Deliver feedings through a syringe barrel attached to the NG tube
d. Deliver the feeding by pushing on the syringe plunger
e. Aspirate the stomach contents
f. Clamp the NG tube once the feeding is complete
54. A patient with chronic mental health problems has been making progress with treatment. During the most
recent visit to the clinic, however, the patient tells the nurse he lost his job and feels useless because he is
unable to provide for the family. Which nursing diagnosis would be most appropriate for this patient?
a. Social isolation
b. Caregiver role restrain
c. Situational low self-esteem
d. Anxiety
55. To minimize the side effects of a DPT immunization for a six-month-old, the nurse should instruct the parents
to:
a. Give the child an alcohol bath for an elevated temperature
b. Administer antipyretics for discomfort, irritability, and fever
c. Place an ice bag on the childs leg for three days
d. Check the childs temperature every four hours for three days
56. On admission, the vital signs of a client with a closed head injury were temperature of 98.6F, blood pressure
128/68mmHg, heart rate 110beats/min, respiration 26. One hour after admission, the nurse observes that the
client may be experiencing Cushings triad. Which vital signs are indicative of Cushings triad?
a. Blood pressure 110/70mmHg, heart rate 120beats/min, respiration 30
b. Blood pressure 130/72mmHg, heart rate 90beats/min, respiration 24
c. Blood pressure 152/88mmHg, heart rate 122beats/min, respiration 16
d. Blood pressure 150/70mmHg, heart rate 80beats/min, respiration 14
57. A female client is diagnosed with human papillomavirus (HPV). Which of the following client statements, if
made to the nurse, illustrates an understanding of the possible sequelae of this illness?
a. I will need to take antibiotics for at least a week.
b. I will use only prescribed douches to avoid a recurrence.
c. I will return for a Pap smear in six months.
d. I will avoid using tampons for eight weeks.
58. The nurse is caring for a client with a cervical spinal cord injury. Vital signs and laboratory results for this client
are as follows:
Blood pressure: 128/72 mmHg
Heart rate: 94 beats/min
Arterial pH: 7.3
Arterial pCO2: 60 mmHg
Arterial pO2:75 mmHg
Arterial HCO3: 35 mEq/L
Based of this information which nursing action would be the best action?
a. Notify the physician, request an order for midazolam, and reevaluate the client in 30 minutes
b. Evaluate airway patency, place the client in high Fowlers position, and encourage coughing and deep
breathing
c. Notify the physician, inform the physician about the clients metabolic acidosis and anticipate a sodium
bicarbonate continuous infusion
d. Evaluate airway patency, administer pain medication and encourage coughing and deep breathing

59. A patient diagnosed with gout asks, Is there anything I can do to decrease my uric acid levels? What is the
nurses most appropriate response?
a. Avoid strenuous activity, as it will cause muscle breakdown.
b. Decrease the amount of liver, sardines, and shrimp in your diet
c. Increase the amount of citrus fruits in your diet
d. Drink at least 1 to 1.5 liters of fluid each day.
60. During the nursing history interview, a preschool clients mother reports that the child has frequent bouts of
gastroenteritis. It would be most important for the nurse to ask which of the following questions?
a. Are there other children in the family?
b. Does the child attend a day care center?
c. Does the child play with neighborhood children?
d. Is the child current on his immunizations?
61. A 9-year-old client is given his heparin injection on time, but it was administered intravenously instead of
subcutaneously. The incident was discovered 2 hours after administration. Which plan would be most
appropriate?
a. Document the event on an incident report and notify the physician
b. Hold the next scheduled heparin dose
c. Order a PTT and INR levels and notify the physican
d. Assess for evidence of bleeding and notify the parents
62. A client is diagnosed with lung cancer and undergoes a pneumonectomy. In the immediate postoperative
period, which of the following nursing assessment is most important?
a. Presence of breath sounds bilaterally.
b. Position of the trachea in the sternal notch.
c. Amount and consistency of sputum.
d. Increase in the pulse pressure.
63. The nurse receives a phone call from a nursing assistant who states that her five-year-old child has developed
chickenpox. It would be most important for the nurse to ask which of the following questions?
a. Have your other children had chickenpox?
b. Does your child have a temperature?
c. Have you had the chickenpox?
d. Do you have someone to watch your child?
64. Mr. Holloway has just received his first dose of this antipsychotic medication perphenazine (Trilafon) you know
that the response time to the medication for cognitive and perceptive symptoms, such as hallucinations,
delusions and thought broadcasting, may take how long?
a. From 28-52 weeks
b. Up to 3 minutes
c. Up to 30 minutes
d. From 2 to 8 weeks
65. A patient who is 28 weeks pregnant complains of lower back pain. What should the nurse suggest?
a. The patient take Motrin as needed
b. Lower back pain is part of being pregnant and there is nothing the patient can do about the pain
c. The patient pay close attention to her body posture and mechanics, as these are the cause of back pain
in pregnancy
d. The patient tell her provider immediately, because she is in preterm labor
66. The nurse has collected the following data: client anger directed toward staff in the form of frequent sarcastic
or crude comments, increased wringing of hands, and purposeless pacing, particularly after the client has used
the telephone. Based on this data, the nurse should make which nursing diagnosis?
a. Impaired social interaction related to conversion reaction
b. Risk for potential activity intolerance as evidenced by purposeless pacing
c. Powerlessness in hospital situation
d. Ineffective individual coping related to recent anger and anxiety
67. An adult patients prescription reads as follows, Infuse 80 mEq of potassium chloride in 100 cc D5W over 30
minutes. Based on the nurses understanding of potassium administration, what is the most appropriate action?
a. Contact the prescriber about the order

b. Monitor the EKG during the medications administration

c. Switch the administration route to oral
d. Administer the medication
68. The nurses aide comes to take a woman by wheelchair for a magnetic resonance imaging (MRI) scan of the
head and neck. Which of the following observations, if made by the nurse, would require an intervention?
a. The woman removes her dentures and gives them to her husband.
b. The womans vital signs are: BP 120/70, pulse 80, respirations 12, temperature 99F (37.3C).
c. The woman has a nitroglycerine patch on her right chest area.
d. The woman has red nail polish on her fingers and toes.
69. A middle-aged man is admitted to an inpatient psychiatric unit. Over the last several months he has become
convinced that his brother is trying to steal his property. He is diagnosed with paranoid disorder. The nurse
knows that this client is demonstrating which of the following
a. Delusions of persecution
b. Command hallucination
c. Delusions of reference
d. Persecution hallucination
70. A client returns to the unit from the recovery room following a laryngoscopy. Which position would be most
effective in helping the client breathe?
a. Side-lying position
b. Sims position
c. Low fowlers position
d. Trendelenburg position
71. For the
a.
b.
c.
d.

following herbal supplement, select the purported use of: Black cohosh (Cimcifugaracemosa)
Used to relieve symptoms associated with benign prostatic hypertrophy
Used to relieve symptoms of menopause
Used to relieve depression
Used to improve memory, sharpen concentration and promote clear thinking

72. What is the highest priority in providing care to a client who is admitted to the hospital with sickle cell crisis?
a. Insist the client rest instead of visiting with family
b. Administer prophylactic antibiotics
c. Initiate intravenous fluids to maximize hydration
d. Insert urinary catheter to measure accurate output
73. To maintain normalized blood sugars, Mr. Hernandez has the following sliding scale insulin prescription:
Blood glucose < 130mg/dl: administer 0 unit of insulin
Blood glucose 130-160mg/dl: administer 2 unit of insulin
Blood glucose 161-190mg/dl: administer 4 unit of insulin
Blood glucose 191-220mg/dl: administer 6 unit of insulin
Blood glucose 221-250mg/dl: administer 8 unit of insulin
Blood glucose >250mg/dl: administer 10 unit of insulin and contact the physician immediately
Mr. Hernandez blood sugar is 122. What is your intervention?
a. administer 2 unit of insulin
b. administer 4 unit of insulin
c. administer no of insulin and contact the physician immediately
d. administer no insulin
74. A patient with Alzheimers disease doesnt want to take a bath, what will the nurse do?
a. Call two staff nurses to help you bathe the patient
b. Attempt to bathe the patient slowly and calmly
c. Ask the patient the reason why she doesnt want to take a bath
d. Document refuse to take a bath
75. Mr. Allen has psychosis and has been treated with haloperidol (Haldol). You need to assess him for movement
disorders as a side effect of Haldol. What is another name for these movement disorders?
a. Delusion etiologies
b. Extrapyramidal reactions
c. Autonomic dysreflexia
d. Biologic rigidity reactions

76. Identify the location on the chest area where the nurse would take an apical pulse.
a. Right 5th intercostal space, midclavicular line
b. Left 8th intercostal space
c. Right 8th intercostal space
d. Left 3rd intercostal space, midclavicular line
77. A client with deep vein thrombophlebitis suddenly develops dyspnea, tachypnea, and chest pain. What is the
nurses initial, most appropriate action?
a. Apply 100% oxygen via face mask
b. Obtain a 12-lead ECG
c. Assess the clients blood pressure and heart rate
d. Auscultate for abnormal heart sounds
78. The nurse is planning discharge for a group of clients. It is most important to refer which of the following
clients for home care?
a. A postoperative appendectomy client who is complaining of incisional pain
b. A diabetic client who had a cardiac catheterization in the early AM
c. A postoperative cholecystectomy client who is complaining of incisional pain
d. A client with congestive heart failure who underwent diuresis in the hospital
79. Which instruction would be given to a client who is receiving oral methylprednisolone regarding when and how
to take the medication?
a. Once a day before bedtime
b. Consume 10-12 glasses of water per day
c. Once a day on an empty stomach
d. Once a day with breakfast
80. A patient with osteoarthritis has had hip replacement surgery. What level of activity would the nurse anticipate
for the first postoperative day?
a. Paresthesia, rigidity, aphasia
b. Tremors, rigidity, bradykinesia
c. Spasticity, diplopia, paresthesia
d. Dysarthria, dysphagia, ataxia
81. A patient with acute coronary syndrome is administered thrombolytic therapy. Which portion of the EKG tracing
would the nurse observe to determine the effectiveness of the medication?
a. ST segment elevation
b. PR interval
c. QT interval
d. Width of QRS complex
82. The nursing assistant reports to the nurse that a client who is one-day postoperative after an angioplasty is
refusing to eat and states, I just dont feel good. Which of the following actions, if taken by the nurse is
best?
a. The nurse talks with the client about how he is feeling
b. The nurse instructs the nursing assistant to sit with the client while he eats
c. The nurse contacts the physician to obtain an order for an antacid
d. The nurse evaluates the most recent vital signs recorded in the chart
83. An 18 month old client is admitted to the hospital with a fever of 104F, respirations of 56/min, suprasternal
retractions and a pulse oximeter reading of 85%; the infant is also drooling. Acute epiglottitis is suspected.
Which equipment would be important to have at the bedside?
a. Tracheostomy tray
b. Intravenous infusion pump
c. Defibrillator
d. Code cart
84. Match the eating disorder with the correct description of the disease. An excessive concern over gaining weight
and a refusal to maintain a minimally normal body weight.
a. Bulimia nervosa
b. Anorexia nervosa

85. Among the four patients, who warrants immediate attention?

a. Patient taking Glucophage with glucose reading of 185mg/dl
b. Patient who had a spinal injury and is complaining of throbbing headache
c. Patient diagnosed with seizure who wants to change medication time
d. Patient with osteoarthritis experiencing joint stiffness
86. Which drug would the nurse anticipate administering for the treatment of inflammation of acute exacerbations
of gout?
a. Allopurinol (Zyloprim)
b. Acetaminophen (Tylenol)
c. Probenecid (Benemid)
d. Colchicine (novocholchicine)
87. A client returns to the unit undergoing a right modified radical mastectomy with dissection of the axillary
lymph nodes. Which measure is an appropriate intervention for the nurse to include in the clients
postoperative care?
a. Encourage the client to obtain a permanent breast prosthesis upon discharge from the hospital
b. Instruct the client to watch the clock and use the PCA pump every 10 minutes
c. Insist that the client examine the surgical incision when the surgical dressings are removed
d. Post a sign at the bedside to avoid pressure measurements or venipunctures in the right arm.
88. Patient
a.
b.
c.
d.

with HIV states, I am so tired, my life is useless, I am going to die anyway.

Refer to support group
Why are you tired?
What is the specific cause that makes you feel tired?
Do you think you are dying?

89. After receiving a total hip replacement, the client returns to the unit with an abductor pillow in place. The
client informs the nurse that he would be more comfortable without the pillow. What is the nurses best
response?
a. The pillow is intended to prevent the inadvertent movement of the left leg beyond the bodys
midline.
b. The pillow is intended to prevent early ambulation if you should wake up confused.
c. The pillow is intended to prevent the inadvertent movement of the left leg too far way from the
body.
d. The pillow is intended to prevent the contact of both knees and reduce the risk that pressure ulcers
will form.
90. The triage nurse for a womens health center receives a phone call from each of the following women. Which
woman should be directed to come to the health care facility immediately?
a. A multipara woman who is four weeks pregnant and reporting unilateral, dull, abdominal pain.
b. A primipara woman who is seven weeks pregnant and reporting increase in whitish vaginal secretions.
c. A primigravida woman who is five weeks gestation and is having vaginal spotting and some cramping.
d. A multigravida woman who is six weeks pregnant and reporting frank, red vaginal bleeding with
moderate cramps.
91. Erythromycin ophthalmic ointment 0.5% is given immediately after an infant is born to provide prophylaxis
against:
a. Chlamydia trachomatis
b. Syphilis
c. Both Neisseria gonorrhoea and chlamydia trachomatis
d. Neisseria gonorrhoea
92. Which food choice would be most appropriate for a patient with osteoporosis who wants to increase calcium
intake?
a. 1 ounce of cream cheese
b. 1 medium stalked of cooked broccoli
c. 3 ounces of beef
d. 1 medium apple
93. Which EKG tracing would the nurse recognize as an early indicator of hyperkalemia?

a.
b.
c.
d.

Depressed ST segment
Prolonged QT interval
Shallow, flat, inverted T wave
Tall peaked T-wave

94. A 4-year-old has been admitted with second-degree burns and is undergoing debridement of the wounds.
Morphine 1 mg IV push has been administered. Following administration of this medication, the nurse makes
the following observations:
Pulse: 96
Respirations: 28
Blood pressure: 84/62
Child sleeping quietly
Which nursing action is most appropriate?
a. Keep the code cart at the bedside
b. Allow the child to sleep quietly
c. Administer nalozone (Narcan)
d. Administer 100% oxygen
95. Individuals with diabetes mellitus can have a chronic complication in which there is pain in the lower
extremities due to lack of blood supply. What is the complication called?
a. Retinopathy
b. Claudication
c. Stroke
d. Angina
96. The nurse is assessing an infant who had a repair of a cleft lip and palate. The respiratory assessment reveals
that the infant has upper airway congestion and slightly labored respirations. Which of the following nursing
actions would be most appropriate?
a. Elevate head of the bed
b. Suction the infants mouth and nose
c. Position the infant on one side
d. Administer oxygen until breathing is easier
97. Why is maintaining a thermoneutral environment essential for the neonate?
a. A thermoneutral environment permits the neonate to maintain a normal core temperature with
increased caloric consumption
b. Metabolism slows dramatically in the neonate who experiences cold stress
c. The neonate produces heat by increasing activity and shivering
d. A thermoneutral environment permits the neonate to maintain a normal core temperature with
minimum oxygen consumption
98. A six-month-old infant has had all the required immunizations. The nurse knows this would include which of the
following?
a. Two doses of diphtheria, tetanus, and pertussis vaccine
b. Measles, mumps and rubella vaccines
c. A booster dose of trivalent oral polio vaccine
d. Chickenpox and smallpox vaccines
99. A 4-year-old child presents with possible rheumatic fever. Which findings will the nurse observe in this patient?
a. Decreased antistreptolysin-O titer
b. Decreased erythrocyte sedimentation rate
c. Macular rash that is pruritic
d. Elevated C-reactive protein levels
100.
The nursing evaluation of the respiratory status of a 3-year-old client who is newly admitted with acute
epiglottitis would indicate the following findings:
a. Drooling, decreased pulse and stridor
b. Irritability, drooling and absence of spontaneous cough
c. Irritability, coarse crackles bilaterally and low-grade fever
d. Croupy cough, high fever and hoarseness

101.
A client with necrotizing spider bite is to perform his own dressing changes at homes. The nurse is
aware that which of the following statements, if made by the client, indicates understanding of aseptic
technique?
a. I need to buy sterile gloves to redress this wound.
b. I should wash my hands before redressing my wound.
c. I should keep the wound covered at all times.
d. I should use an over-the-counter antimicrobial ointment.
102.
A 22-month-old child is hospitalized for heart failure. During the night, the child awakens crying and
calling for the mother. The nurse assesse the child and notes dyspnea, jugular vein distention, crackles and
pink, frothy sputum. After the nurse begins oxygen by 40% face mask, which action should be taken next?
a. Dim the lights and allow the mother to rock the child to sleep
b. Continue to monitor the client frequently and increase fluid rate
c. Place the child in a crib with a blanket and notify the physician
d. Stay with the child and call for assistance to notify the physician
103.
patient
a.
b.
c.
d.

An elderly patient has been prescribed aspirin for osteoarthritis. What should the nurse teach the
to ensure safe use of this medication?
A prothrombin time should be drawn upon initiation of therapy and every 2 months
The prescriber should be notified if the patient experiences any unusual bruising or bleeding
The medication should be taken on an empty stomach
Enteric-coated tablets should be crushed to make the medication easier to swallow

104.
return
a.
b.

The nurse is caring for client in the outpatient clinic. Which of the following messages should the nurse
first?
A mother reports that the umbilical cord of her five-day-old infant is dry and hard to touch.
A mother reports that the soft spot on the head of her four-day-old infant feels slightly elevated
when the baby sleeps.
c. A mother reports that the circumcision of her 3-day-old infant is covered with yellowish exudate.
d. A father reports that her bumped the crib of his two-day-old infant and she violently extended her
extremities and returned to their previous position.

105.
Indomethacin is given as a treatment for preterm labor. What is a potentially significant fetal side
effect of this drug?
a. Premature closure of the ductusvenosus
b. Bradycardia
c. Decreased fetal movement
d. Premature closure of the ductusarteriosus
106.
nurse,
a.
b.
c.
d.

The nurse is caring for a client with internal radiation. Which of the following actions, if taken by the
is most important?
Restrict visitor who may have an upper respiratory infection
Assign only male caregivers to the client
Plan nursing activities to decrease nurse exposure
Wear a lead-lined apron whenever delivering client care

107.
The nurse is caring for a client who sustained severe burns and has an inhalation thermal injury. The
client is intubated and on the ventilator at 60% FiO2. The nurse notices that the client is restless, thrashing,
and attempting to cough, the respiratory rate is 34. What should the nurses first action be?
a. Administer pain medication
b. Increase the FiO2 setting to 100%
c. Auscultate lung sounds and suction if needed
d. Notify the physician and prepare for immediate surgery
108.
A 22-month-old client is receiving Nystatin 200,00 units via oral swab every 6 hours. For which side
effects should the nurse assess the client?
a. Leukopenia
b. Oral thrush
c. Diarrhea
d. Thrombocytopenia

109.
The nurse is performing discharge teaching on a client with multiple sclerosis. It is most important for
the nurse to include which of the following instructions?
a. Ambulate as tolerated every day
b. Avoid overexposure to heat or cold
c. Perform stretching and strengthening exercises
d. Participate in social activities
110.
A client is being prepared for surgical repair of an abdominal aortic aneurysm. The nurse suspects
complete aortic dissection when:
a. The client becomes hypotensive and unresponsive
b. A bruit and thrill are palpable at the aneurysm site
c. The client becomes hypertensive and tachycardic
d. The client complains of sever leg and arm pain
111.
The nurse is caring for patients on the surgical floor and has just received report from the previous
shift. Which of the following patients should the nurse see first?
a. A 35-year-old admitted 3 hours ago with a gunshot wound, 1/5 cm area of dark drainage noted on the
dressing.
b. A 43-year-old who had mastectomy two days ago, 23 cc of serosanguinous fluid noted in the JacksonPratt drain
c. A 59-year-old with a collapsed lung due to an accident, no drainage noted from the chest tube in the
last eight hours
d. A 62-year-old who had an abdominal-perineal resection three days ago, patient complains of chills
112.
Which of the following statements, if made by the parents of a nine-year-old client with an ostomy,
would indicate to the nurse that they are providing quality home care?
a. We change the bag at least once a week and we carefully inspect the stoma at that time.
b. We change the bag every day so that we can inspect the stoma and the skin.
c. We encourage our daughter to watch TV while we change her ostomy bag.
d. We only change the ostomy bag every ten days.
113.
a.
b.
c.
d.

Nursing care in the first 30 minutes after a caesarean section includes:

Fundal and lochial assessment
Ambulation
Vital signs every hour
Oral hydration and nutrition

114.
Education about health promotion is often effective during periods of role transitions. Which of the
following is a role transition?
a. Retirement
b. Buying a new car
c. Moving into a new house in the same neighbourhood
d. Going grocery shopping
115.
and he
a.
b.
c.
d.

An extremely angry patient with bipolar illness tells the nurse he just learned his wife filed for divorce,
needs to use the phone. Which of the following responses by the most nurse is most appropriate?
Allow the patient to use the phone
Confront the patient about his anger and inappropriate plan of action
Do not allow the patient to use the phone because he is an involuntary patient
Set limits on the patients phone use because he has been unable to control his behaviour

116.
A patients medicinal history includes the use of the herbal medication garlic and the prescribed
medication warfarin (Coumadin). Based in the nurses knowledge of drug-drug interactions, which problem
could occur when a patient takes both of these products concurrently?
a. Elevated blood pressure
b. Decreased immune function
c. Altered renal perfusion
d. Increased bleeding potential
117.
Which statement by a patient would indicate that the patient is adapting well to changes in functional
status after experiencing a spinal cord injury?

a. I tire easily when I use my wheelchair just around the house. I know I would get tired if I tried to
leave the house.
b. "My wife tries to get me to go to the grocery store, but I don't like to go out much."
c. "I have all the equipment to take a shower, but I prefer a bed bath, because it is easier."
d. "I have been using the modified feeding utensils at every meal. I still have spills, but I'm getting
better."
118.
A client is receiving plasmapheresis treatments for myasthenia gravis. Which observation would the
nurse identify as the desired response for this treatment?
a. Increased ptosis
b. Decreased functional residual capacity
c. Ability to consume an entire meal
d. Need for frequent rest periods
119.
A client is brought to the emergency room after a motor vehicle accident that resulted in the client
sustaining a head injury. Which assessment should the nurse perform immediately?
a. Assessment of the respiratory status
b. Assessment of pupils
c. Assessment of short-term memory
d. Assessment of motor function
120.
a.
b.
c.
d.

To promote safety in the environment of a client with a marked depression of T cells, the nurse should:
Keep a linen hamper immediately outside the room
Restrict eating utensils to spoons made of plastic
Provide masks for anyone entering the room
Remove any standing water left in containers or equipment

121.
A nurse is caring for a client with a spinal cord injury. Which observation would indicate this client is
exhibiting neurogenic shock?
a. Heart rate of 52 beats/min
b. Temperature of 102.5F
c. Heart rate of 115 beats/min
d. Cool, moist skin
122.
should
a.
b.
c.
d.

The nurse is preparing a teaching plan for a patient who is visually impaired. Which teaching strategy
be included in the plan?
Provision of written information
Use of captioned video materials
Auditory or tactile materials
Use of a slow, deliberate speech pattern

123.
A 19-year-old patient has just been admitted to the detoxification unit after drinking a quart of vodka
every day for the past 3 weeks. What is the most important nursing intervention on the day of admission to
reduce the risk of harm to this patient?
a. Give the patient a meeting schedule for Alcoholic Anonymous
b. Administer Librium as prescribed
c. Encourage the patient to attend group therapy sessions
d. Explain the addictive process to the patient
124.
The physician informs the nurse that a client needs to be intubated. In preparing for the physician to
perform the intubation, which equipment is appropriate for this procedure? (SATA)
a. Laryngoscope
b. Sterile gloves
c. Uncuffed endotracheal tube
d. Oral suction
e. Face mask
f. Ambu bag
125.
A 23-year-old man comes to the AIDS clinic for treatment of large, painful, purplish-brown open areas
on his right arm and back. The nurse should instruct the client to:
a. Clean the area carefully with soap and warm water every day and cover them with sterile dressing
b. Soak in a warm tub twice a day and rub the areas with a washcloth before covering them

c. Shower daily using a mild antimicrobial soap from a pump dispenser and leave the lesions uncovered
d. Clean the lesion twice a day with a diluted solution of povidone-iodine (Betadine) and leave them open
to the air
126.
The nurse is admitting a client to the unit from the postoperative recovery area after abdominal
exploratory surgery. After determining the clients vital signs, which of the following activities should the nurse
perform next?
a. Position the client on her left side, supported with pillows
b. Check the chart and determine the status of the fluid balance from surgery
c. Check the clients abdominal dressing for any evidence of bleeding
d. Monitor the incision and pulmonary status for the presence of infection
127.
A physician has written an order for an HIV-positive infant to receive an oral polio immunization. Which
of the following nursing actions is most appropriate?
a. Wear gloves and gown when administering the immunization
b. Administer the immunization as infant is being discharged
c. Call the physician and discuss the rationale for the immunization
d. Administer the medication in the same manner as you would to any other infant
128.
Mrs.Tungen, who has been diagnosed with bipolar disorder, is receiving lithium and outpatient
therapy.She now complains of diarrhea, vomiting, thirst, and coarsening hand tremors. What should the nurse's
first intervention be?
a. Hold the lithium, and call for an order to obtain a lithium level.
b. Administer an antidiarrheal medication.
c. Obtain a stool sample for culture.
d. Begin an intravenous drip of D5 NS with 20 mg potassium chloride to infuse at 125 mL/h.
129.
The nurse observes a client who is taking phenelzine (Nardil) eating another clients lunch. After a few
minutes, the client complains of headache, nausea, rapid heartbeat, and begins to vomit. The nurse
anticipates administering which of the following medication?
a. Buspirone (Buspar)
b. Fluoxetine (Prozac)
c. Prochlorperazine (Compazine)
d. Nifedipine (Procardia)
130.
An infant born with spina bifida and is scheduled for surgery the next day. Which nursing action has the
greatest priority?
a. Preventing infection by supine positioning
b. Encouraging the parents to hold, cuddle and feed the infant
c. Promoting range-if-motion exercises
d. Preventing rupture of the meningocele sac
131.
The nurse is caring for a client admitted with acute hypoparathyroidism. It is most important for the
nurse to have which of the following item available?
a. Tracheostomy set
b. Cardiac monitor
c. IV monitor
d. Heating pad
132.
a.
b.
c.
d.

Which assessment finding indicates effective chest compressions during CPR?

Pink mucous membranes
Palpable carotid pulse
Dilated pupils bilaterally
Sluggish capillary refill

133.
A nasogastric tube is ordered to be placed in a client. Organize the following steps in chronological
order as they relate to this procedure:
1. Lubricate the tube
2. Measure the tube for approximate placement length
3. Place the client in a high Fowlers position
4. Advance the tube downward and backward
5. Insert the tube along the base of the nose

6. Check the position of the tube, and secure the tube

a. 3,1,2,5,4,6
b. 2,3,1,5,4,6
c. 1,3,2,5,4,6
d. 3,2,1,5,4,6
134.
A client has been receiving chlorpromazine hydrochloride (Thorazine). When the nurse checks on the
patient, the patient is restless, unable to sit, and complains of insomnia and fine tremors of the hands. The
nurse identifies which of the following as the best explanation about why these symptoms are occurring?
a. A side effect of the medication that will disappear as time passes.
b. The reason the patient is receiving this medication.
c. Extrapyramidal side effects resulting from this medication.
d. An indication that the dosage of the medication needs to be increased.
135.
A client has a right-side pneumothorax and a chest tube has been inserted. Which finding would
indicate that the chest drainage system is functioning effectively?
a. Blood leaking around the chest tube insertion site
b. Constant bubbling in the water seal chamber
c. Absence of breath sounds on the right side
d. Bubbling in the suction chamber
136.
Your patient, Mr. Lawrence, has been prescribed Mucinex (guaifenesin) 300 mg orally daily as part of his
treatment for bronchitis. The pharmacy sends up Mucinex 600-mg extended-release tablets. How many tablets
doo you give Mr. Lawrence?
a. 2 tablets
b. None
c. 0.5 tablet
d. 1 tablet. None.
137.
On the second day after a subtotal thyroidectomy, the client informs the nurse that she is experiencing
numbness and tingling around her mouth. What is the nurses best first action?
a. Notify the physician
b. Order a thyroid-stimulating hormone level
c. Loosen the neck dressing
d. Offer mouth care
138.
1.
2.
3.
4.
5.
6.
139.

Select all self-care activities that persons should be able to perform prior to discharge to home. (SATA)
Bathing
Banking
Dressing
Car oil change
Grooming
Hygiene
a.
b.
c.
d.

When to know if a 6 year old child has a dysfunctional grieving after the death of a grandparent?
The child refuses to eat and stays in his room
The child re-enacts the funeral using his stuff toys and pets
The child asks when he can play with grandpa just after visiting his grave
The child states that his grandpa is just sleeping and would wake up soon

140.
Mr. Koo is prescribed chlorpromazine (Thorazine) as an antipsychotic medication. When he comes to
the pill line in the hospital, he reports that he has taken 2 days worth of the medication as prescribed and is
now experiencing dizziness. What should your first nursing intervention be?
a. Obtain a complete blood count and serum ammonia level as prescribed
b. Assess blood pressure with the patient In both the lying and standing positions
c. Assess the optic chiasm using an ophthalmoscope
d. Obtain pulmonary function test, stat
141.
A 9-year-old client is receiving one unit of packed red blood cells. Which finding on assessment would
indicate a possible haemolytic reaction? (SATA)
a. Tightness in chest
b. Red or black urine

c.
d.
e.
f.

Shaking
Temperature of 97.6F
Flank pain
Bilateral crackles

142.
The nurse is supervising the staff caring for clients on the medical/surgical unit. The nurse observes
the student nurse enter wearing a gown, gloves, and a mask. The nurse determines that the precautions are
correct if the student nurse is caring for which of the following clients?
a. An infant diagnosed with respiratory syncytial virus
b. A young child with a wound infected with S. aureus
c. A teenager diagnosed with toxic shock syndrome
d. A teenager diagnosed with rubella (German measles)
143.
A client is admitted in sickle cell crisis and is receiving IV morphine by PCA pump. The nurse makes the
following observations:
Pulse: 73
Respirations: 6
Blood pressure: 112/72 mmHg
Client is quietly sleeping
Which nursing action is most appropriate?
a. Allow the client to sleep quietly
b. Administer 100% oxygen
c. Administer naloxone (Narcan) as prescribed
d. Keep the code cart at the bedside
144.
An autoimmune disorder attacks the myelin sheaths of nerve fibers in the central nervous system and
produces lesions called plaques. This statement describes the pathophysiology of which disease?
a. Amyotrophic lateral sclerosis
b. Multiple sclerosis
c. Alzheimers disease
d. Myasthenia gravis
145.
The multipdisciplinary team decides to implement behaviour modification with a client. Which of the
following nursing actions is of primary importance during this time?
a. Confirm that all staff members understand and comply with the treatment plan.
b. Establish mutually agreed upon, realistic goals.
c. Ensure that the potent reinforcers (rewards) are important to the client.
d. Establish a fixed interval schedule for reinforcement.
146.
When completing discharge teaching for a patient who has experienced a myocardial infarction, the
patient asks the nurse why aspirin has been prescribed daily. What is the nurses best response?
a. The medication helps to maintain coronary blood flow by decreasing platelet aggregation in the
coronary arteries.
b. Aspirin is used to prevent fever associated with the inflammatory response in myocardial infarction.
c. The medication increases the amount of blood in the coronary arteries.
d. Aspirin is used as prophylactic analgesic to reduce pain.
147.
a.
b.
c.
d.

Which immunization should be withheld if patient experiences seizures?

Hepatitis
DPT
OPV
Measles

148.
A 2-month-old infant is 2 days postoperative tracheoesophageal fistula repair. A complete blood count
reveals a haemoglobin of 8.6mg/dl and erythrocyte count of 2.5 million/mm 3. Which symptoms would the nurse
most likely find on assessment?
a. Projectile vomiting after oral bottle feeding
b. Sluggish capillary refill and hypotension
c. Slight pallor and tires easily while crying
d. Tachycardia and flushing

149.
The nurse is caring for a patient with acute coronary syndrome who is receiving altaplase (tPA). Which
side effects should the nurse monitor the patient for?
a. Hepatomegaly
b. Fluid retention
c. Bleeding
d. Muscle pain
150.
a.
b.
c.
d.

Lamotrigine is given to clients to relieve them from what?

Seizure
Joint stiffness
Blood pressure
Migraine

151.
One of the goals the nurse and a client with posttraumatic stress disorder (PTSD) mutually agreed upon
is that he will increase his participation in out-of-the apartment activities. Which of the following
recommendations, if made by nurse, will be most therapeutic to achieve this goal?
a. Take a day trip with a friend
b. Take an eleven-minute bus ride alone
c. Join a support group and participate in a victim assistance organization
d. Take a ten-minute with his wife around the block
152.
a.
b.
c.
d.

The client is at risk for bleeding related to the Vitamin K deficiency and the altered liver functions
Roasted chicken breast, baked potato with margarine and chives and skim milk
Two eggs, two slices of toast with margarine and a glass of whole milk
Baked fish, steamed broccoli with salt and pepper, and a glass of iced tea
Grilled cheese sandwich, steamed vegetables with butter and a cup of coffee

153.
During a home visit, the nurse saw an old woman filthy and unkempt in her childs house. What should
you do?
a. Advise the woman to visit the hospital
b. Talk to the child of the old woman
c. Call the abuse center for the elderly
d. Perform hygiene care for the old woman
154.
A patient has a subcutaneous terbutaline (Brethine) pump for treatment of preterm labor. Which of the
following findings warrants a call to the physician?
a. Fetal movements are fewer than 12 per hour
b. The patient feels nervous and jittery
c. The patients pulse is 124 beats per minute
d. Fetal movements are more than 12 per hour
155.
The nurse is teaching a client how to perform self-monitoring blood glucose (SMBG) using a blood
glucose monitor. Which of the following actions, if performed by the client indicates to the nurse the need for
further teaching?
a. The client lets her hand dangle before sticking her finger with the lancet
b. The client sticks her finger on the side of the distal pharynx
c. The client touches the strip with a large drop of blood from her fingertip
d. The client milks her finger after sticking it
156.
A bipolar patient refuses to put down the mop that he is swinging to threaten other patients and staff.
What information is most important for the nurse to consider before administering a PRN IM dose of lorazepam
(Ativan)?
a. The patient is harmful to himself
b. The patient is psychotic
c. A restrictive intervention failed
d. The patient is harmful to others
157.
A client is admitted to the burn unit with a third-degree burn to the chest, face, and upper
extremities. During the acute phase (i.e., first 48 hours) of a major burn injury, which assessment findings
should the nurse report immediately?
a. Temperature of 100F
b. Edema of hands
c. Decreased sensation in the extremities

d. Urinary output of 200 ml over 8 hours

158.
A 19-month old child weighs 22 pounds and has an order of 200 mcg digoxin to be given intravenously.
You have a vial of digoxin at a concentration of 0.1mg/ml. how many millilitres of the solution will you need to
deliver the ordered dose?
a. 0.22 mL
b. 0.002 mL
c. 2.0 mL
d. 0.2mL
159.
Mrs. Langley has hyperosmolar nonketotic coma with hyperglycemia. She begins to experience CNS
dysfunction. What is most likely source of this dysfunction?
a. Adrenal gland tumor
b. Cellular fluid loss
c. Fever
d. Hypoxia
160.
The nurse is supervising a care given to clients on a medical/surgical unit. The nurse should intervene
if which of the following is observed?
a. A nurse and client wear masks during a dressing change for the central catheter used for total
parenteral nutrition
b. A nurse injects insulin through a single-lumen percutaneous central catheter for client receiving total
parenteral nutrition
c. A nurse applies lip balm to his/ her lips immediately after performing a blood draw to obtain specimen
d. A nurse wears a disposable particulate respirator when administering rifampicin to a client
withtuberculosis.
161.
A patient is in 8 cm dilated, 90% effaced and -3 station when her water breaks. Immediately thereafter,
the fetal heart rate decelerates in the 60s. the nurse knows:
a. This could be a sign of uterine rupture
b. This could be a sign of cord prolapse
c. This is a normal fetal heart pattern
d. This is a normal fetal heart pattern
162.
Which statement by a patient with a history of major depression indicates that he is not maintaining
good health in his current environment?
a. Going back to work, well, its not bad; its okay.
b. I just dont like going to the movies like I did before.
c. I cant wait to go to my sons wedding next weekend. It will be nice to have the whole family
together.
d. I had a great trip to the Smokey Mountains. It was fun.
163.
The nurse knows that which of the following mood altering drugs is most often associated with an
increased risk for HIV infection related to intravenous drug use?
a. Benzodiazepines
b. Marijuana
c. Barbiturates
d. Narcotics
164.
A 7-year-old child is diagnosed with insulin-dependent diabetes mellitus. The child and parents are
being taught what should occur if the child presents with signs and symptoms of hypoglycaemia. Which
statement if made by the parents would indicate an understanding of the teaching?
a. It is important to decrease the amount of long-acting insulin.
b. It is important for the child to rest in bed until the symptoms subside.
c. It is important to increase activity prior to insulin administration.
d. It is important for the child to eat 4-6 lifesavers candies or drink orange juice.
165.
A urinalysis has been obtained on a client who has been complaining of dysuria, urinary frequency, and
discomfort in the suprapubic area. After evaluating the results, the nurse should order a repeat urinalysis based
on which of the following findings?
a. Negative glucose
b. RBCspresent

c. No WBCs or RBCs reported

d. Specific gravity 1.018
166.

a.
b.
c.
d.

The client is to have EMG. Which of the following is the correct instruction?
Ask the client for allergies to seafoods
Tell the patient that he may experience discomfort because of the needles to be used
Put the patient on NPO 6-8 hours
Ask the patient to empty the bladder

a.
b.
c.
d.

Indicated use of magnesium sulphate in pregnancy is:

To prohibit preterm labor
Both prohibit preterm labor and prevent seizure
To trigger breast milk letdown
To prevent seizures

167.

168.
The nurse is caring for a client with perforated bowel secondary to bowel obstruction. At the time the
diagnosis is made, which of the following should be a priority in the nursing are plan?
a. Maintain the client in a supine position
b. Notify the clients next of kin
c. Prepare the client for emergency surgery
d. Remove the nasogastric tube
169.

a.
b.
c.
d.

Which action would be the first priority when caring for a client in anaphylaxis?
Administer an antibiotic
Administering oxygen via face mask
Obtaining vascular access
Preventing future antigen exposure

170.
The home health nurse is performing a follow-up visit for a 76-year-old man receiving isoniazid (INH)
200 mg every day for 6 months. The nurse would be most concerned if the client made which of the following
statements?
a. I have blurred vision at times.
b. My legs and knees hurt.
c. My hands and feet tingle.
d. I think I had a migraine yesterday.
171.
The nurse is obtaining a history on a client just admitted to the unit. The client informs the nurse that
any information shared with the nurse during the interview is to remain confidential. Which of the following
responses by the nurse is best?
a. Ill share any information you give me with staff members only.
b. If the information you share is important to your care, Ill need to share it with the staff.
c. We can keep the information just between the two of us.
d. I have an obligation to maintain nurse/patient confidentiality about anything you tell me.
172.
After abdominal surgery, a client is admitted from the recovery room with intravenous fluid infusing at
100cc/hr. One hour later, the nurse finds the clamp wide open and notes that the client has received 850cc.
The nurse would be most concerned by which of the following?
a. A CVP reading of 12 and bradycardia
b. Tachycardia and hypotension
c. Dyspnea and oliguria
d. Rales and tachycardia
173.
a.
b.
c.
d.

What is the cause of blindness due to diabetic retinopathy?

Haemorrhage
Tiny lesions in the tear ducts
Acidosis
Scar tissue

174.
A staff member informs the nurse that his six-year-old child has head lice. It is most important for the
nurse to take which of the following actions?
a. Inspects the staff members head for louse and nits
b. Inform the staff member that he cannot care for clients until further notice

c. Request that the staff member contact the physician

d. Instruct the staff member about how to use Kwell
175.
To help prevent polypharmacy interactions in a client who is taking multiple prescriptions, what
instruction would the nurse give to the client?
a. Use a dispensing system as a reminder to take medications on a schedule
b. Inform a family member of the names and uses of all medications
c. Bring all medications, including supplements and herbal remedies to the doctors appointment
d. Abstain from taking any over-the-counter medications in addition to the medication you are already
taking
176.
A 7-year-old client is scheduled for a cardiac catheterization. Which priority nursing assessment finding
to report to the physician?
a. The child has an allergic reaction of hives to shellfish
b. The child insists on taking a stuffed teddy bear to the procedure
c. The child has cool lower extremities with brisk capillary refill bilaterally
d. The child has diminished palpable pedal pulses bilaterally
177.
A 6-month-old infant has returned to the unit from surgery. Which assessment finding would indicate
that the infant was experiencing pain?
a. The child cries steadily and kicks
b. The child points to the area producing the pain
c. The child has a rating of 6 on the Faces Pain Rating Scale
d. The child sleeps soundly, with an increased pulse rate and decreased blood pressure
178.

179.

180.

a.
b.
c.
d.

Which of the following would the nurse see first?

Psychotic patient with delusion
Severe depression with suicide ideation
Patient with anxiety who is agitated
Patient with bipolar manic phase

a.
b.
c.
d.

A client presents with hypoparathyroidism. Which assessments will the nurse make with this client?
Nephrolithiasis
Serum calcium level of 6.8 mg/dL
Positive Chvosteks sign
Serum phosphorus level of 5.2mg/dL

a.
b.
c.
d.

In which situation is the patient most likely to experience anticipatory grieving?

The patient experiences traumatic amputation of an extremity in an industrial accident
A patient is brought into the Emergency Room and declared brain dead
After diagnostic testing, a patient is diagnosed with metastatic liver cancer
A patient finds out that her symptoms were from an ectopic pregnancy

181.
A nurse notices ventricular tachycardia on the cardiac monitor at the nurses station and goes to the
clients room. What is the first action the nurse should take in assisting this client?
a. Start cardiopulmonary resuscitation
b. Check the patients airway
c. Establish unresponsiveness
d. Alert the physician on call
182.
The clinic nurse observes that a ten-year-old child with leukemia has a large bum on her arm and the
bum appears to be oily. The client states that she touched a hot pan and her mother put cooking fat on it so it
would not blister. The nurse should:
a. Document the findings in the chart
b. Call the physician immediately to report the injury
c. Teach the client that oil holds germs and makes infection more likely
d. Wash the burn with soap and water to remove the oil
183.
The nurse is caring for a client postoperatively following removal of a pituitary tumor. Which
observation would alert the nurse to the possible development of diabetes insipidus (DI)?
a. Weight gain
b. Peripheral edema

c. Urinary output of greater than 200mL/hr

d. Serum sodium of 150 mEq/L
184.
The nurse is making a home visit for a client with an abdominal wound. When irrigating the draining
wound with a sterile saline solution, which of the following sequences would be most appropriate for the nurse
to follow?
a. Pour the solution, wash hands and remove the soiled dressing
b. Wash hands, prepare the sterile field and remove soiled dressing
c. Prepare the sterile field, put on sterile gloves, and remove the soiled dressing
d. Remove the soiled dressing, flush the wound and wash hands
185.
A client underwent a cerebral angiogram through the right femoral site. Which post-procedural nursing
assessments would justify calling the physician? (SATA)
a. Equal, bilateral radial pulse
b. Bilateral pink, warm toes
c. Blood pressure of 88/52 mmHg
d. Pulse 122
e. Right pedal pulse weaker than left pedal pulse
f. Respiration 22
g. Intact dressing that needs reinforcement due to bloody drainage
186.

a.
b.
c.
d.
e.
f.

Which factor may contribute to the development of osteoarthritis? SATA

Excessive use of alcohol
20 to 20 years of age
Obesity
Caucasian or Asian ethnicity
Regular strenuous exercise
Family history of osteoarthritis

187.
An adult client is brought into the Emergency Deparment in cardiac arrest. Cardiopulmonary
resuscitation (CPR) is being performed. Name the area where the pulse should be checked.
a. Ulnar or radial pulse
b. Dorsalispedis pulse
c. Brachial pulse
d. Carotid pulse
188.
A client has a nasogastric tube in place after extensive abdominal surgery. The client complains of
nausea. His abdomen is distended and there are no bowel sounds. The first nursing action should be to:
a. Administer the PRN pain medication and an antiemetic
b. Irrigate the nasogastric tube with normal saline
c. Determine if the nasogastric tube is patent and draining
d. Check the placement of the nasogastric tube by auscultation
189.
Which emergency medication should the nurse initially administer to a client in pulseless electrical
activity?
a. Lidocaine 4mg/min IV infusion
b. Atropine 1.0mg IV push
c. Epinephrine 1.0mg IV push
d. Amiodarone 400 mg IV push
190.
The nurse knows which of the following would have the greatest impact on an elderly clients ability to
complete activities of daily living (ADLs)?
a. Perseveration
b. Aphasia
c. Mnemonic disturbance
d. Apraxia
191.
The nurse is administering furosemide (Lasix) to a patient who has edema associated with congestive
heart failure. What is the most appropriate parameter for the nurse to monitor regarding effectiveness of this
drug?
a. Urine specific gravity

b. Serum potassium level

c. Daily weight
d. Abdominal girth measurement
192.
A 30-year-old woman is admitted to the hospital with dry mucous membranes and decreased skin
turgor, the womans vital signs are BP 120/70, temperature 101F (38.3C), pulse 88, respirations 14. Laboratory
tests indicate the serum sodium is 150 mEq/L and Hct is 48%. The nurse expect the physician to order which of
the following IV fluids?
a. D5NSS
b. 0.45% NaCl
c. 0.9% NaCl
d. Lactated Ringers
193.

a.
b.
c.
d.

Which of the following condition are associated with impaired glucose tolerance (IGT)?
Hypoglycaemia and prostatitis
Obesity and hypotension
Obesity and syndrome X
Hypotension and hyperlipidemia

194.
You are teaching a patient who is newly diagnosed with diabetes, how to choose healthy snacks. Of the
following foods, which is the best choice for your patient?
a. Chocolate chip cookies with nuts
b. Ice cream
c. Buttered popcorn
d. Baked chips and salsa
195.
The clinic nurse is obtaining a throat culture from a client with pharyngitis. It is most important for the
nurse to do which of the following?
a. Quickly rub a cotton swab over both tonsillar areas and the posterior pharynx
b. Obtain a sputum container for the client to use
c. Irrigate with warm saline and then swab the pharynx
d. Hyperextend the clients head and neck for the procedure
196.

197.

a.
b.
c.
d.

Which measures should the nursing care of a client with hypothyroidism include?
Planning frequent rest periods
Providing cool environment
Encouraging the use of heating pad
Provide a low-calorie, high-protein diet

a.
b.
c.
d.

The nurse is drawing up a vitamin K injection for a newborn. What should the dose be?
1-2 mg
0.5-1 mg
10-50 mg
12 mL

198.
Which statement by a nurse in response to a patient would be an example of a reflective question or
comment?
a. How do you feel when you take the medication?
b. Tell me what occurred first- did your symptoms occur before or after you took the medication?
c. What time do you take your medication?
d. Youve been upset about your blood pressure.
199.
A patient undergoing hip replacement surgery who is at risk for the development of deep vein
thrombosis is receiving dalteparin (Fragmin). Which statement correctly describes the administration technique
for the medication?
a. Use an 18-guage, 1 inch needle to administer the drug
b. Inject the medication into the muscle within 2 inches of the umbilicus
c. Aspirate prior to administering the medication
d. Administer the medication by subcutaneous route
200.
The nurse is caring for patients in an acute renal care facility. The nurse would identify which of the
following patients as a likely candidate for developing acute renal failure?

a.
b.
c.
d.

A young female with recent ileostomy due to ulcerative colitis

A middle-aged male with elevated temperature and chronic pancreatitis
A teenager in hypovolemic shock following a crushing injury to the chest
Child with compound fracture on the right femur and massive laceration of the left arm

ANSWER
1. C. Compulsive behavior is an unconscious attempt to control and/or relieve the tension and anxiety the client
is experiencing It is not a manipulation on the clients part. Client is not subject to depression but to high
levels of anxiety.
2. D. Infant suckling cause the posterior pituitary to release oxytocin, which is a hormone that contracts the
uterus.
3. A. Options B&D are symptoms of hyperthyroidism. Option C are symptoms of hypothyroidism (myxedema).

4. B. ECG changes can indicate potentially lethal arrhythmias such as ventricular fibrillation, which can occur in
hyperkalemia.
5. A. Graves disease results from an increased production of thyroid hormone. It is state of hypermetabolism.
The increased metabolic rate generates heat and produces tachycardia and fine muscle tremors. Patients are
encourage to have frequent rest periods, and are advised to avoid strenuous physical activity. Management
include the use of antithyroid drugs (propylthiouracil or Tapazole), radioactive iodine, or surgical removal of a
portion of the gland.
6. C. Early signs of lithium toxicity are Fine tremors, nausea, vomiting, diarrhea. Late signs include Ataxia,
confusion, seizures
7. A, D, E, F. The presence of frankly bloody emesis (hematemesis) suggests moderate to severe bleeding that
may be ongoing, whereas coffee-ground emesis suggests more limited bleeding. Melena may be seen with
variable degrees of blood loss, being seen with as little as 50 mL of blood. Hematochezia (red or maroon blood
in the stool) is usually due to lower GI bleeding. However, it can occur with massive upper GI bleeding, which is
typically associated with orthostatic hypotension.
8. B.
9. B. Consolidation will result in diminished breath sounds over the lobes involved. Wheezing results from
constricted airways such as in asthma. Bronchovesicular breath sounds are normal lung sound. Hyperresonance
results from percussing an excessively air-filled lung or pleural space.
10. C. Atropine has a vagolytic effect as well as blocks muscarinic responses and has selective depression of
central nervous system. Benadryl is an H-1 receptor antagonist and antihistamine with anticholinergic activity
and does not protect against vagal bradycardia. Adrenalin is a catecholamine that constricts bronchioles and
inhibits histamine release, and Prozac is a antidepressant.
11. D.
12. C. The suicide of her son puts this patient at high risk of suicide. This risk is exacerbated by the betrayal of her
husband and best friend.
13. C. *
14. C. Notify the if there is arm or hand numbness, coldness, tingling, swelling, or pain
15. C.
16. A. Four main methods of treatment exist for a patient with Pagets disease, pharmacological therapy using
either bisphosphonates or calcitonin; pain management using analgesics; surgery; and non-pharmacological
therapy (focusing mainly on physical therapy as a means of improving muscle strength to help control some
types of pain).
17. C. Fine macular rash during ciprofloxacin administration indicates hypersensitivity reaction, should stop
medication and notify the physician. Option A does not warrants an immediate concern. Option B, PTT is within
normal limits, should give medication. Option D, should decrease rate to prevent irritation of the vein.
18. A.
19. A. Condition is often called spastic bowel disease. Options B & C refer to inflammatory bowel disease such as
ulcerative colitis or Crohn's disease. Bloody stools do not occur.
20. D, E. Clots or fresh blood in the nose or throat, frequent swallowing, clearing of the throat, and vomiting of
dark blood are indications of possible bleeding. Check the back of the patient's throat with a flashlight for
trickling of blood. Decreased BP, tachycardia, pallor, and restlessness are hallmark signs of hemorrhage and
should be reported to the surgeon immediately.
21. C. Carvedilol is a nonselective beta-adrenergic antagonist that blocks the action of beta 1 receptors in the heart
and the action of beta2 receptors in the lung, smooth and skeletal muscles. Blocking the beta 1 receptor leads to

deacreased heart rate, contractility and velocity of impulse conduction in the atrioventricular node. Beta 2
receptors blockade can result in bronchoconstriction and inhibition of glycogenolysis. Because of this drugs
effect on the heart, the nurse should assess the patients current pulse and blood pressure before
administering carvedilol. The prescriber should be contacted if bradycardia or hypotension is identified prior to
administration of the drug. Carvedilol is administered orally.
22. B. First signs of acute rejection are usually a rash, burning, and redness of the skin on the palms and soles.
This can spread over the entire body. Other symptoms include nausea, vomiting, stomach cramps, diarrhea
(watery and sometimes bloody), loss of appetite, yellowing of the skin and eyes (jaundice), abdominal (belly)
pain, weight loss.
23. A.
24. D. Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled
then. There is no decrease in sensation with MG, and muscle atrophy does not occur because muscles are used
during part of the day.
25. B.
26. B. Magnesium sulfate is a central bervous system depressant and relaxes smooth muscles. Adverse effects
include flushing, depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle
weakness, decreased urinary output, pulmonary edema and elevated serum magnesium levels.
27. B. Stress ulcers or Curling's ulcers are acute ulcerations of the stomach or duodenum that form following the
burn injury.
28. C. Olanzapine (Zyprexa) is an atypical antipsychotic drug given to patients with schizophrenia. Key treatments
for obsessive-compulsive are benzodiazepines and SSRIs. Fluoxetine (Prozac) and other SSRIs are given to
patients with bulimia nervosa. Seroquel is an atypical antipsychotic. Buspar is an anxiolytic drug.
29. B. Raynauds disease is characterized by attacks of vasospasms in the small arteries and arterioles of the
fingers and sometimes the toes. The disease primarily affects young women and can be triggered by exposure
to cold.
30. D. Utilization of an MDI requires coordination between activation and inspiration; deep breaths to ensure that
medication is distributed into the lungs, holding the breath for 10 seconds or as long as possible to disperse the
medication into the lungs, shaking up the medication in the MDI before use, and a sufficient amount of time
between puffs to provide an adequate amount of inhalation medication.
31. C.
32. B.
33. C.
34. B. The pathology behind PIH is a fluid shift that occurs from the vasculature to the tissues, which causes edema
and leads to an increase in hematocrit.
35. A.
36. C.
37. A. SIADH is a condition in which the client has excessive levels of antidiuretic hormone (ADH) and cant excrete
the diluted urine. Therefore, the client retains fluids. This disorder causes a dilutional hyponatremia.
38. A.
39. A, C, E. An endoscopic retrograde cholangiopancreatography is anendoscopic test that provides radiographic
visualization of the bile and pancreatic ducts. Postprocedural care after the ERCP include monitoring the vital
signs and maintaining an NPO status until the gag reflex returns. The client probably received sedating

medication before the procedure; consequently, lethargy is expected. A local anesthetic is sprayed into the
clients throat, so it is possible that the gag and cough reflexes will not be present. The client should be
monitored for signs of cholangitis and perforation, which include fever, abdominal pain (especially in the RUQ),
hypotension and tachycardia.
40. D. Ibandronate (Boniva) is a bisphosphonate drug. In giving such drugs the nurse should instruct the client to
swallow the whole tablet, it should not be chewed. It should be taken in the morning on an empty stomach
with large glass of water (6-8oz) and wait at last 30 minutes before eating or lying down. Make sure the client
has adequate intake of Vitamin D. Instruct the client to report any signs and symptoms of gastric reflex or pain.
41. B.
42. C. The airway is compromised by the bleeding in the esophagus and aspiration easily occurs.
43. A. Dye is injected into subarachnoid space before an x-ray of spinal cord and vertebral column to assist in
identifying spinal lesions; if client is allergic to dye, there is a major safety issue. It is important that client
drink extra fluids AFTER the test to replace CSF lost during test and to flush out the dye. Option C is
appropriate for MRI.
44. D. Client is under constant observation; must not be left alone for any reason
45. C.
46. C. Stridor on exhalation is a hallmark of respiratory distress, usually caused by obstruction resulting from
edema. One emergency measure is to remove the surgical clips to relieve the pressure. In some settings, this
may be a nursing action; in other settings, this is a physician function. Emergency intubation also may be
necessary.
47. A.
48. B. Option A & D, reveals normal values: BUN 718 mg/dL; creatine 0.61.2 mg/dL; AST (formerly SGOT) 820
U/L, ALT (formerly SGPT) 820 U/L, bilirubin 0.11.0 mg/dL . Amphotericin B causes renal and liver toxicity.
Check liver and renal function studies weekly, notify the physician if elevated. Option C are not side effects of
the medication.
49. B.
50. D.
51. A, C, F.
52. A. Robust means strong and healthy. Pulse pressure of 40 is normal. All other options reveal abnormal
assessment.
53. C, E, F.
54. C. This patient has experienced a loss (job) that is contributing to his feelings of uselessness to his family. The
diagnosis of situational low self-esteem is the most appropriate diagnosis for this patient. The North American
Nursing Diagnosis Association (NANDA) definition for the nursing diagnosis is the development of a negative
perception of self-worth in response to a current situation.
55. B. Antipyretics relieve the combination of side effects. Ice bag is dangerous to both skin integrity and overall
temperature control. Option D is unnecessary unless indicated for another reason.
56. D. Cushing's triad is systolic hypertension with a widening pulse pressure, bradycardia with a full and bounding
pulse, and slowed respirations. The rise in blood pressure is an attempt to maintain cerebral perfusion, and it
is a neurologic emergency because decompensation is imminent.
57. C. Several strains of the human papillomavirus (HPV) are associated with cervical cancer. Antibiotics are not
used for viral infections. Douches will not prevent recurrence of the disease. Tampons would not be a problem
as in toxic shock syndrome.

58. B.
59. B.
60. B. Environments with increased numbers of children (day care) more likely to promote infections due to close
living conditions and increased likelihood of disease transmission. Option A & D do not pose a problem or
solution regarding gastroenteritis. Neighbourhood is a possible source of infection, but not as likely as a day
care center.
61. A.
62. B. Position of the trachea should be evaluated; with a tracheal shift, an increase in pressure could occur on the
operative side and could cause pressure against the mediastinal area. On the surgical side, breath sounds will
be absent. Sputum is important to observe but not as high a priority. Pulse pressure does not relate to the
situation
63.
64. A.
65. D.
66. C.
67. D.
68. A. Potassium chloride must be diluted and administered at a rate no faster than 20mEq/hr
69. C. Nitroglycerin patch should be removed before the test. Dentures are removed removed before the test.
Option B, results are within normal limits. It is unnecessary check capillary refill.
70. A. Delusion of perseceution is a strongly held belief that is not validated bu reality, for example, the idea that
his brother is trying to steal his property is not validated by reality. Delusion of reference is a false belief that
public events or people are directly related to the individual.
71. C.
72. A.
73. C. During a sickle cell crisis, increasing the transport and availability of oxygen to the body's tissues is
paramount. Administering a high volume of intravenous fluid and electrolytes to help compensate for the
acidosis resulting from hypoxemia associated with sickle cell crisis is one way to accomplish this. Fluid
administration also helps overcome dehydration, a possible predisposing factor common in clients with sickle
cell crisis.
74. D.
75. C.
76. B. Extrapyramidal reactions include movement disorders such as dystonia, tardive dyskinesia, and
pseudoparkinsonism.
77. A.
78. A.
79. D.
80. D.
81. B.

82. A. ECG monitoring of acute coronary syndrome: features that increase the likelihood of infarction are: new STsegment elevation; new Q waves; any ST-segment elevation; new conduction defect. Other features of
ischaemia are ST-segment depression and T-wave inversion.
83. A.
84. A.
85. B.
86. B.
87. D.
88. D. The patient is at risk for lymphedema and infection if blood pressures or venipuncture are done on the right
arm. The patient is taught to use the PCA as needed for pain control rather than at a set time. The nurse
allows the patient to examine the incision and participate in care when the patient feels ready. Permanent
breast prostheses are usually obtained about 6 weeks after surgery.
89. C.
90. A. After a total hip replacement, it is important to maintain the hip in a state of abduction to prevent
dislocation of the prosthesis. Use of an abduction pillow or splint will not prevent the formation of sacral
pressure ulcers. An abduction pillow may also be used to keep the legs shoulder width apart and to prevent
rotation of the hips, and avoid crossing the leg beyond the midline of the body (e.g. not crossing the leg over
the other leg).
91. A. Among the 4 women, the least stable patient is the patient experiencing unilateral dull abdominal pain. The
pregnant woman needs to be evaluated immediately for ectopic pregnancy. Option B is expected during first
trimester of pregnancy. Option C is symptomatic of threatened abortion, should be instructed to decrease
activity. Option D symptoms suggest of spontaneous abortion and should be instruct client to pads. Ectopic
pregnancy needs more emergent intervention as compared to abortion.
92. C. Instillation of erythromycin into the neonates eyes provides prophylaxis for opyhalmia neonatorum or
neonatal blindness caused by gonorrhoea in the mother. Erythromycin is also eefctive in the prevention of
infection and conjunctivitis from Chlamydia trachomatis. The medication may result in redness of the
neonates eyes, but this redness will eventually disappear. Erythromycin ointment is not effective in treating
neonatal chorioretinitis from cytomegalovirus. No effective treatment is available for a mother with
cytomegalovirus.
93. B.
94. D. EKG changes in hyperkalemia: Peaked T waves; Widened QRS complexes; prolonged PR intervals; Flat P
waves
95. B.
96. B.
97. C.
98. D. The temperature range during which the basal metabolic rate of the baby is at a minimum, oxygen
utilization is least and baby thrives well is known as 'Thermo- neutral range of temperature' or 'Neutral Thermal
Environment'. For each baby, this range of temperature varies depending on gestational age.

99. A. first dose of the DPT may be given at two months, the second is given around four months. MMR is given at
15 months. Polio is given at two and four months and again at 12 to 18 months. Smallpox vaccine is no longer
recommended.
100.
D. Diagnosis of rheumatic fever is based on the Jones criteria and positive laboratoty tests for:
Increased erythrocyte sedimentation rate; positive C-reactive protein; positive antistreptolysin-O titer; positive
throat culture for group A beta haemolytic streptococci; prolonged PR and QT intervals, revealed by ECG.
101.
B. The absence of spontaneous cough and presence of drooling and agitation are cardinal signs
distinctive of epiglottitis.
102.
B. Hallmark of aseptic technique is handwashing. Client should use only the prescribed medications on
the wound.
103.

D.

104.
B. Take the drug with food or after meals if GI upset occurs. Do not cut, crush, or chew sustainedrelease products. Report ringing in the ears; dizziness, confusion; abdominal pain; rapid or difficult breathing;
nausea, vomiting, bloody stools, easy bruising, gum bleeding (related to aspirins effects on blood clotting).
105.
B. Fontanelle should feel soft and flat; fullness or bulging indicates increased intracranial pressure.
Umbilical cord falls off within 1 to 2 weeks; no tub baths until the cord falls off. Normal healing of
cirucmcision, don't remove exudate; clean with warm water. motor reflex is normal; disappears after 3 to 4
months.
106.

D.

107.
C. Principles for radiation therapy are time, distance, shielding; nurse should decrease the time spent
in close proximity to the client. All visitors are restricted with regard to the distance they should be from the
client. Appropriate shielding (lead aprons) is to be used when the nurse has to spend any length of time at a
close distance, not just for routine care.
108.

C.

109.

C. Nystatin is given for candida infections such as oral thrush. A common side effect is diarrhea.

110.

B.

111.
A. Signs and symptoms of abdominal aortic aneurysm include: diminished femoral pulses, lower back
and abdominal pain, pulsatile abdominal mass, bruit over site, BP difference between extremities, peripheral
ischemia.

112.
D. Patient is at risk for peritonitis, and should be assessed for further symptoms of infection. Option A
reveals small amount of bleeding and does not indicate acute bleeding. Option B suggests expected outcome.
Option C indicates resolution.
113.
A. Ostomy bags should be changed at least once a week or when seal arpunf stoma is loose or leaking;
during change of bag isa good time for stoma and skin to be closely inspected. Client should be encouraged to
participate and should foster independence.
114.

A.

115.

A.

116.
A. Patient has not lost civil right to use phone. Patient is able to use phone unless otherwise indicated
by court order or physicians order.
117.
D. Garlic, a lipid lowering-agent, increase bleeding potential with aspirin, NSAIDs and warfarin.
118.
D. A goal when caring for patients with spinal cord injuries is to promote their adjustment to the injury
and their independence. A patient who is using modified feeding utensils at every meal is demonstrating an
attempt at independence for the functional activity of eating. The patient's statement recognizes that the
activity is one that requires continued work, but progress is being made toward the goal of developing as much
independence as possible with eating.
119.

C. Other options suggest exacerbation of the disease.

120.

A.

121.
D. Water should not be allowed to stand in containers, such as respiratory or suction equipment
because this could act as a culture medium.
122.
A. Neurogenic shock is characterized by areflexia. In neurogenic shock, vasodilation occurs as a result
of a loss of balance between parasympathetic and sympathetic stimualtaion. The patient experiences a
predominant parasympathetic stimulationthat causes vasodilation lasting for an extended period. It is
manifested by hypotension, due to a reduction in systemic vascular resistance and venous return; warm, dry
skin; bradycardia, due to dominance of the parasympathetic system (vagus nerve); flaccid paralysis, including
bowel and bladder; hypothermia, due to vasodilation.
123.

C.

124.
B. By administering Librium, you will prevent delirium tremens that can possibly harm during the
process.
125.

A, D, E, F.

126.
A. Open Kaposis sarcoma lesions should be cleaned and dressed daily to prevent secondary infection.
Warm tub bath is not done because of risk of secondary skin infection. It is important to keep the skin clean to
prevent secondary skin infection but should be covered due to open areas. Diluted povidone-iodine is the
treatment for herpes simplex virus abscess, not Kaposis sarcoma.
127.
C. Assessment of the dressing should be checked on admission to the room and frequently for the next
several hours. Option A is an Implementation, complete assessment first. Option B is an assessment but
determine what is happening to the patient now. Option D is an inappropriate assessment, it is too soon for
infection to occur secondary to surgery.
128.

C. Polio vaccine contains live virus and should not be given to children who are immunocompromised.

129.
A. Unsteady gait, slurred speech, nausea, vomiting, diarrhea, thirst, and coarsening of hand tremors
indicate lithium toxicity.
130.
D. Hypertensive crisis, an adverse effect of this medication, is characterized by hypertension, frontally
radiating occipital headache, neck stiffness and soreness, nausea, vomiting, sweating, fever and chills, clammy
skin, dilated pupils, and palpitations. Tachycardia, bradycardia, and constricting chest pain may also be
present. The client is taught to be alert to any occipital headache radiating frontally and neck stiffness or

soreness, which could be the first signs of a hypertensive crisis. Hypertensive crisis is treated with (Nifedipine)
Procardia.
131.

D.

132.

A. Tracheostomy set is the most important for the client's safety due to risk for laryngospasm.

133.

B.

134.

D.

135.
C. Extrapyramidal side effects resulting from this medication include akathisia (motor restlessness),
dystonias (protrusion of tongue, abnormal posturing), pseudoparkinsonism (tremors, rigidity), and dyskinesia
(stiff neck, difficulty swallowing). The dosage may need to be decreased because of side effect of medication;
antiparkinsonian drug such as Cogentin may be ordered. Option B is not accurat, Thorazine is an antipsychotic
medication.
136.

D.

137.

B. You should not cut extended-release tablets in half.

138.

A. The patient may be experiencing hypocalcemia.

139.

A, C, D, E.

140.

C.

141.
B. Postural hypotension can be a result of dizziness owing to the use of low-potency antipsychotics such
as chlorpromazine or thioridazine.
142.
A,B,C,E. Hemolytic Reaction is a type of complication of blood transfusion is caused by infusion of
incompatible blood products. Assessment include Low back pain (first sign). This is due to inflammatory
response of the kidneys to incompatible blood; Chills; Feeling of fullness; Tachycardia; Flushing; Tachypnea;
Hypotension; Bleeding; Vascular collapse; Acute renal failure.
143.
D. Droplet precautions used for organisms that can be transmitted by face-to-face contact, door may
remain open. Option A&B require contact precautions with no mask. Option C requires standard precautions.
144.
C. Naloxone is a narcotic antagonist that can reverse the effects, both adverse and therapeutic, of
opioid narcotic analgesics. Morphine is an opioid narcotic analgesic that can depress respiration.
145.

B.

146.
A. To implement a behavior modification plan successfully, all staff members need to be included
in program development, and time must be allowed for discussion of concerns from each nursing staff member;
consistency and follow-through is important to prevent or diminish the level of manipulation by the staff or
client during implementation of this program.
147.

A.

148.

149.

C.

150.

C. Alteplase is a tissue plasminogen activator which induce fibrinolysis that causes bleeding.

151.
A. Lamotrigine, marketed in the US and most of Europe as Lamictal by GlaxoSmithKline, is an
anticonvulsant drug used in the treatment of epilepsy and bipolar disorder. It is also used off-label as an
adjunct in treating depression. For epilepsy, it is used to treat focal seizures, primary and secondary tonicclonic seizures, and seizures associated with Lennox-Gastautsyndrome.

152.
C. Support groups of people who have suffered similar acts of violence can be helpful and supportive to
teach clients how to deal with the traumatizing situation and the emotional aftermath. Other options are
reasonable recommendations to begin using in a systematic desensitization program after the crisis is
alleviated.
153.

C. Vitamin K food sources are green leafy vegetables, cauliflower and cabbage.

154.
C. The nurse must immediately call and report the suspected abuse. Failure to report abuse is a
misdemeanor.
155.

C.

156.
D. Milking forces interstitial fluid to mix with capillary blood and dilutes the blood. Dangling helps
facilitates venous congestion. Sticking on the side is less painful that the center of the fingertip. Blood should
sit on the strip like a raindrop, smearing alters the reading.
157.

C. Use the least restrictive interventions in ascending order.

158.
D. Acute phase of burn injury occurs from beginning of diuresis to the near completion of wound
closure Characterized by fluid shift from interstitial to intravascular. Urinary output of less than 30ml/hr should
reported to the physician.
159.

C. 1 milligram = 1000 mcg

160.
B. In HHNS, CNS depression, disorientation or mental confusion, seizures, and coma are caused by
intracellular dehydration and hyperosmolarity. CNS dysfunction worsens as serum osmolarity rises.
161.
C. Applying lip balm or handling contact lenses is prohibited in work areas where exposure to
bloodborne pathogens may occur. Option A demonstrates appropriate procedure, prevents airborne
contamination. Insulin is the only medication that can be given, compatible with TPN. Use airborne precautions
for TB, private room with negative air pressure, minimum of six exchanges per hour.
162.

B.

163.

B. Anhedoniathe loss of interest and pleasure in activitiesis a sign of depression.

164.

D. Narcotics are most often used intravenously

165.

D. Candy or another simple sugar is carried and used to treat mild hypoglycemia episodes.

166.
C. With the clients complaints, WBCs and RBCs should be present; WBCs are a response to the
inflammation process and irritation of the urethra; RBCs are increased when bladder mucosa is irritated and
bleeding. Glucose increases during the inflammation process; it is not a primary component in determining
urinary tract infections.
167.
A.
(B.) Electromyography (EMG) assesses electrical activity associated with nerves and skeletal muscles. Needle
electrodes are inserted to detect muscle and peripheral nerve disease. You should inform the patient that pain
and discomfort are associated with insertion of needles. There is no risk of electric shock with this procedure.
168.
B. Magnesium Sulfate is used to reduce preterm labor contractions and prevent seizures in PreEclampsia
169.

C.

170.

B.

171.

C. Isoniazid/INH can causes peripheral neuritis. Vit B6/Pyridoxine is given.

172.
B. The nurse is obligated to share client information with personnel directly involved with the clients
care. The nurse must never agree to keep information confidential without knowing the content of the

information. The nurse is not obligated to report information that is not relevant to the clients care or wellbeing.
173.

D. Indicates cardiovascular fluid overload.

174.

A. Diabetic retinopathy leads to development of microaneurysms and intraretinal haemorrhage.

175.
A. Observe for movement (louse) or small whitish oval specks that adhere to the hair shaft (nits); treat
with gamma-benzene hexachloride (Kwell). Confirm the presence of lice before excluding from duty; if lice
present, exclude from patient care until appropriate treatment has been received and shown to be effective.
Assessment should be done first. Apply Kwell shampoo to dry hair and work into lather for 45 minutes
176.

C. Polypharmacy means that multiple medications have been prescribed.

177.
dye.

A. People who have an allergy to shellfish or iodine may experience an allergic reaction to the contrast

178.

A.

179.

B.

180.

C.

181.
C. Grief can be classified as acute, anticipatory, or pathologic. Anticipatory grief is associated with the
anticipation of a death or loss that has yet to take place. A patient who is newly diagnosed with liver cancer is
most likely to experience anticipatory grieving when anticipating death.
182.

C.

183.
D. Because leukemic clients are immunosuppressed, they are more susceptible to infections; cooking
fat applied to an open wound increases the possibility of infection; burns should be rinsed immediately with
tap water to reduce the heat in the burn. Documentation is done later, and does not address the immediate
problem of cleansing the wound. Reporting the physician is unnecessary unless signs of wound infection is
noted.
184.

C.

185.
B. Handwashing should be done prior to beginning any procedure, especially irrigating a wound. Using
sterile gloves to remove the dressing would contaminate them.
186.

D,E,G.

187.

C,D,F.

188.
D. During CPR, the carotid artery pulse is the most accessible and may persist when the peripheral
pulses (radial and brachial) no longer are palpable because of decreases in cardiac output and peripheral
perfusion.
189.
C. Should first assess if the tube is open and draining to determine if there is a problem with the
nasogastric tube; if it is patent and draining it does not need to be irrigated. Option A & B, may be carried out
after the patency of the tube is determined. Patency should be checked first by aspirating stomach contents,
not by auscultation.
190.

C. The mainstay of drug therapy for PEA is epinephrine 1 mg every 35 minutes.

191.

D.

192.

C.

193.
B. Hypotonic solution, shifts fluid into intracellular space to correct dehydration. Hypertonic solutions
are contraindicated in dehydration. Isotonic solutios are not best with dehydration. Lactated Ringers is an
isotonic solution used to replace electrolytes.
194.

C.

195.

D.

196.
A. To obtain a throat culture specimen, the nurse puts on clean gloves, then inserts the swab into the
oropharynx and runs the swab along the tonsils and areas on the pharynx that are reddened or contain
exudate. The gag reflex, active in some clients, may be decreased by having the client sit upright if health
permits, open the mouth, extend the tongue, and say "ah," and by taking the specimen quickly.
197.

D.

198.

B.

199.
D. The statement "You've been upset about your blood pressure" is a reflective comment that describes
the patient's feelings. A reflective comment repeats what a patient has said or describes the person's feelings.
It is used by the nurse to encourage the patient to elaborate on the topic.
200.

D. Dalteparin is given by subcutaneous (under the skin) injection, usually in the lower abdominal area.

201.

C.