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NCLEX

DIAGNOSTIC EXAMINATION
NAME: Score:____/265 Percentage:____%

1. Upon entering a child’s room, the nurse notes that the child’s chest tube becomes disconnected from the Pleurevac. What should
the nurse do first?
A. Clamp the chest tube closer to the drainage system
B. Apply pressure directly over the incision site
C. Clamp the chest tube near the incision site
D. Reconnect the chest tube to the Pleurevac

2. A client should be able to describe the signs of pacemaker malfunction. Which behavior by the client indicates that this goal has
been met?
A. State the estimated life of the battery, and understands the need for prophylactic replacement
B. Identifies the need to monitor the rate daily
C. Identifies the significance of drainage or discoloration around the battery insertion site
D. Identifies the need to report rate changes and symptoms such as dizziness and hiccoughs

3. What is the most appropriate action for the nurse to take when the high pressure alarm repeatedly sounded on a client’s
ventilator?
A. Check all connection sites on the ventilator
B. Administer cough suppressants as ordered PRN
C. Assess the need to suction excess sputum
D. Administer morphine ordered for “fighting” the ventilator

4. What nursing intervention should be implemented before the deflation of tracheostomy cuff?
A. Take the pulse oximetry reading
B. Have the obturator available
C. Encourage deep breathing and coughing
D. Suction the trachea and mouth

5. A patient with Chronic Renal Failure is being maintained on Peritoneal Dialysis. Which of the following is NOT an indication that
the patient is developing possible Peritonitis?
A. Blood-tinged drainage after two exchanges
B. Rigid abdomen with abdominal pain
C. Decreased rate of fluid return
D. Nausea and vomiting

6. You are caring for a patient with Colostomy. In preparing a teaching plan for this patient which of the following would be an
incorrect statement?
A. Irrigation is necessary since the fecal contents are liquid
B. That the stoma should be dark pink to red in appearance
C. That the bag should be checked when starting new medication to be sure that it is completely dissolved
D. That the bag/appliance should be changed q 2-3 days

7. You are caring for a patient receiving hyperalimentation (Total Parenteral Nutrition). The flow rate ordered is 60cc/hr. After two
hours the patient complains of feeling extremely nauseous, and of having a bad headache. Which of the following would be the
most appropriate intervention by the nurse?
A. Stop the infusion immediately
B. Increase the flow rate as the patient is likely hypoglycemic
C. Decrease the flow rate and observe the patient
D. Check the patient's glucose level and urinary output

8. Which of the following is an abnormal finding when observing water-sealed chest drainage for proper functioning?
A. Bubbling initially with coughing and deep inspiration
B. Continuous bubbling where the water seal is maintained
C. Water level fluctuations with breathing
D. A collection chamber that is less than 1/2 full

9. A patient is receiving Incentive Spirometry post-operatively. Which of the following would demonstrate misunderstanding on the
part of the nurse regarding this treatment modality?
A. The patient should be medicated for pain, PRN prior to beginning the treatment
B. The head of the bed should be elevated to at least 45 degrees
C. The therapy should begin on the second or third post-op day
D. The patient should be taught to hold their breath following inspiration, and then to exhale slowly

10. Which of the following statement is correct about the management of a Hemovac or Jackson-Pratt drainage device?
A. Keep the drainage device uncompressed
B. Assess amount, color, and characteristic of drainage
C. Empty the drainage device every 4 hours
D. Pin the drainage tubing to the sheet

11. What is the appropriate position for conducting thoracentesis?


A. A .Lateral position
B. Lying on bed with the affected side and head elevated at 450
C. Sitting on the edge of bed and leaning forward
D. Semi-Fowlers position

12. A nurse in the intensive care unit (ICU) observes a patient on mechanical ventilator is biting the endotracheal tube. The nurse
would anticipate which alarm to sound?
A. Low pressure alarm
B. Moderate pressure alarm
C. High pressure alarm
D. No alarm

13. Which of the following nursing action during phototherapy needs an intervention?
A. Turning the infant every 2 hours
B. Undress the infant completely under the light
C. Shields the gonads and infant’s eye
D. Drawing blood while the infant is exposed to light

14. The nurse delivers external cardiac compression to a client while performing cardiopulmonary resuscitation (CPR). Which of the
following action by the nurse is best?
A. Check the return of the client’s pulse after every 8 breaths by the nurse.
B. Maintain a position close to the client’s side with the nurse’s knees apart.
C. Maintain vertical pressure on the client’s chest through the heel of the nurse’s hand.
D. Re-check the nurse’s hand position after every 10 chest compressions.

15. A client is receiving packed red blood cells. Several minutes after the infusion is started, the client complains of itching and
develops hives on his chest and abdomen. Which of the following actions should the nurse take first?
A. Slow down the rate of infusion
B. Mix IV fluid with the blood to dilute it
C. Call the physician for an order of an antihistamine
D. Stop the infusion

16. An outpatient nurse is performing percussion on a client during a routine physical examination. Which of the following description
shows a normal sound on a health client?
A. Tympanic over the LUQ
B. Resonance over the dense tissue
C. Dullness over solid mass like spleen
D. Flatness over the umbilical area

17. A victim of a motor vehicle crash has sustained a severe facial injury. In assessing the intactness of cranial nerve III functioning,
the nurse would
A. Observe the patient’s posturing patterns such as flexion or extension
B. Ask the client to open the mouth widely, stick out the tongue, and rapidly move the tongue side to side
C. Observe the face for symmetry and ask the patient to raise the forehead and eyebrow
D. Have the patient follow your moving finger with his eyes as you move it in different direction

18. You are preparing a motorcycle crash victim for a needle thoracentesis. A tension pneumothorax is suspected. After assembling the
needed equipment, you would know that the insertion of a 14-gauge needle would be placed in which location?
A. Unaffected side, fourth intercostals space slightly anterior to the midaxillary line
B. Affected side, second intercostals space at the midclavicular line
C. Affected side, fifth intercostals space lightly anterior to the midaxillary line
D. Unaffected side, third intercostals space at the midclavicular line

19. A staff nurse asked one of the student nurse on which route of drug administration is most appropriate to use when an immediate
analgesia and titration are necessary. The student nurse best response would be?
A. Intravenous (IV)
B. Sublingual
C. Patient-controlled analgesia (PCA)
D. Intramuscular (IM)

20. A client was prescribed with total parenteral nutrition (TPN) via central venous catheter. Which measure should the nurse take to
ensure adequate assessment and to prevent infection while the patient is on TPN?
A. Administering no medications or blood products through the TPN line
B. Changing TPN tubing every 48 hours
C. Taking vital signs every 12 hours
D. Changing TPN dressing every 3 days

21. What is the main reason for cautioning in using analgesia during delivery?
A. Hypoxia in newborn
B. Ability of mother to engage in delivery process
C. Decrease strength of uterine contractions
D. Diminished ability of mother to bear down

22. A nurse admitting a client with PIH would prepare which of the following in the client’s bedside?
A. Suction equipment and oxygen
B. Fetal heart monitor
C. Blood pressure equipment
D. Padded side rails
23. A woman previously used a diaphragm for contraception before her pregnancy. Now at 6 weeks postpartum, she asks the nurse if
she needs to have her diaphragm refitted. The best response is:
A. “No, it is not necessary. Once involution is completed, it should fit as it did before.”
B. “Yes, it should be refitted after pregnancy.”
C. “Yes, but you should wait until 3 months postpartum.”
D. “It isn’t advisable to use a diaphragm after giving birth to an infant.”

24. To prevent displacement of radium implants in the cervix, the nurse should position the client:
A. On the side only
B. With the head elevated at 45 degrees (Semi Fowler’s position)
C. Flat in bed
D. With the foot of the bed elevated

25. Following a mastectomy, what follow-up care should the RN discuss with the client?
A. Change the dressing prn
B. Perform active ROM exercises with the affected arm
C. Resume normal activities as comfort allows
D. Wear rubber gloves when gardening

26. What information should the RN teach the woman with pelvic inflammatory disease (PID)?
A. Douche everyday
B. Refrain from sexual activity for 6 weeks
C. Change tampons at least every 4 hours when menstruating
D. Use an IUD for birth control

27. Health teaching for client with vaginal infection with Candida albicans should be planned and implemented to ensure her consistent
and appropriate use of the prescribed medication. Which medication is effective in the treatment of monilial (yeast) vaginitis?
A. Metronidazole (Flagyl) oral tablets
B. Nystatin (Mycostatin) vaginal suppositories
C. Antibiotic (Bacitracin) ointment
D. Local applications of podophyllin

28. The mother who is in labor will experience a more intense back pain, in what fetal position?
A. Low occiput posterior
B. Transverse position
C. Breech Position
D. Low anteroposterior

29. A 21-year-old woman inactive labor is admitted to the labor suite. An hour later, the membranes rupture spontaneously. The nurse
observes a glistening white cord protruding from the vagina. Which of the following actions should the nurse take first?
A. Place clean sterile gauze over the cord and wet it with sterile normal saline.
B. Return to the nurses’ station and place an emergency call to the physician.
C. Apply manual pressure to the presenting part and have the mother assume a knee-chest position.
D. Administer oxygen by mask at 10-12liter/minute and assess the mother’s vital signs.

30. A home care nurse visits a pregnant client who is being monitored for pregnancy-induced hypertension. Which client complains
would require the nurse to report immediately?
A. “I am experiencing frequent urination.”
B. “I am experiencing an abdominal pain.”
C. “I am noticing tightness in my wedding ring.”
D. “I am loosing weight this past day.”

31. Which of the following lab finding are consistent with a mother to whom the nurse will expect to administer RHoGAM following
delivery?
A. Mother Rh negative with positive Coombs, father Rh negative, baby Rh negative.
B. Mother Rh negative with negative Coombs, father Rh positive, baby Rh positive.
C. Mother Rh negative with positive Rh antibody titer, father Rh positive, baby Rh positive.
D. Mother Rh negative with negative Coombs, father Rh positive, baby Rh negative.

32. A nurse in the labor room is preparing care for a woman who is diagnosed with a prolapsed cord. What are the appropriate
measures for the nurse to take? Select all that apply
A. Prepare for emergency cesarean birth
B. Push the cord inwardly with fingers
C. Elevate fetal head from the cord
D. Provide oxygen to the mother
E. Elevate the mothers hips
F. Administer Rh immune globulin

33. A nurse in the maternity unit is caring for a client with placenta previa. The nurse formulates a plan of care and monitor the client
for which of the following risks associated with placenta previa?
A. Infection
B. Disseminated intravascular coagulation
C. Rh incompatibility
D. Hemorrhage and shock

34. Immediately after administering a lumbar epidural anesthesia to a mother, the nurse would initially assess for
A. Fetal heart rate
B. Maternal BP
C. Headache
D. Intensity of contractions

35. A staff nurse is admitting a 36-year-old multigravida who has pregnancy-induced hypertension. Which of the following observation
made by the staff nurse is consistent with the client’s admitting diagnosis?
A. Weight loss
B. Facial edema
C. Frequent uterine contractions
D. Increased respirations

36. A pregnant woman with fetal death in the utero is continuously monitored for DIC. Which of the following assessment may reveal a
development of the said complication?
A. Vomiting
B. Vaginal spotting
C. Petechial rashes
D. Fever and chills

37. The nurse in the maternity unit is observing for a 36-year-old multigravida who has severe pregnancy-induced hypertension. Which
of this action by the staff nurse would require intervention?
A. Limiting the patient’s visitor to immediate family members
B. Measuring accurate intake and output with each voiding
C. Monitoring for fetal heart rate regularly
D. Maintaining bed rest in a well-lighted room

38. A woman in the delivery room on her first stage of labor is about to receive induction of epidural anesthesia, which of the following
statement indicates that the woman understands the procedure?
A. “I will have an IV infusion.”
B. “I will wait for my membranes to rupture before epidural anesthesia is given.”
C. “I have to void prior to the initiation of anesthesia.”
D. “I have to sit and flexed my head forward during catheter insertion.”

39. A woman wants to submit herself for MMR vaccination. Which client statement during history taking will require the nurse to
withhold the vaccine?
A. “I have allergy to penicillin and eggs.”
B. “I am currently breastfeeding baby.”
C. “My child was given Immunoglobulin 1 month ago.”
D. “My latest pregnancy test was positive.”

40. A client with type I DM wo is on her 3rd trimester of pregnancy is scheduled for cesarean delivery. Which of the following lab value
will require the nurse to report?
A. WBC of 13,000 cells/uL
B. Glucose of 130 mg/dl
C. Platelet of 150,000 cells/uL
D. Hematocrit of 40%

Pediatric 1 - Newborn Care and Growth and Development


41. Which diversionary activity would be most appropriate for the nurse to provide for a 16-month-old who is hospitalized?
A. Jumbo crayons and coloring book
B. Toy xylophone
C. Cardboard puzzles
D. A windup mobile

42. Which recreational activity for a hospitalized adolescent would be most appropriate?
A. School work that can be brought to the hospital
B. A television to watch in the two-bed hospital room
C. Various novels that an adolescent want to read
D. A board game, such as checkers or monopoly

43. Which milestone should the nurse expect an 8-month-old infant to have reached?
A. Rolls over and sits with support
B. Has a three-word vocabulary
C. Transfers objects to another hand
D. Recognizes, but is fearful of strangers

44. Which of the following is appropriate for a 5 year-old child whose mother just recently died?
A. The child thinks it is a punishment for his behavior
B. The child frequently asks why his mother died
C. The child thinks that his mother is only sleeping
D. The child experiences depression and isolation
E.
45. The nurse seeks to provide appropriate diversional activities for a school-age child with chorea associated with rheumatic fever. The
best activity for the nurse to select would be:
A. Cutting out paper dolls
B. Watching educational television
C. String beads to make necklace
D. Assembling a puzzle
46. The grandparents of a 6-month-old infant diagnosed with cerebral palsy asked the nurse to recommend something that they could
purchase for their grandchild to assist with the required care. The best item for the nurse to suggest would be:
A. Feeding utensils that promote independence
B. An infant feeding seat
C. A mobile to hang over the infant’s crib
D. A potty chair

47. Treatment was delayed for a 4-year-old child with congenital hip dysplasia. The child has now undergone surgery and is on a spica
cast. Which object should the nurse immediately remove from the child’s bed because of its potential safety hazards?
A. Legos
B. A sponge ball
C. A stuffed animal
D. A toy gun

48. The nurse should know that the client who is at risk for a developmental problem is:
A. A 5-year-old with asthma on cromolyn sodium
B. A 4-year-old who frequently suffers tonsillitis
C. A 3-year-old with acute glomerulonephritis on antihypertensives and antibiotics
D. An 18-month-old with cystic fibrosis

49. A 15-year-old white male child with cystic fibrosis is experiencing increasing shortness of breath, cough and sputum production,
fatigue, and weight loss. Which of the following actions is inappropriate for the child?
A. Allowing the child to set his own goals so that he can accomplish it all.
B. Performing CPT twice daily or more frequently if needed.
C. Administering pancreatic enzymes during meals or snacks.
D. Encouraging a high-protein, high-calorie diet

50. An 8-year old child develops juvenile rheumatoid arthritis. Which of the following measures are not advisable to the child?
A. Administer aspirin initially to relieve pain
B. Encouraging exercise in a pool
C. Applying hot packs during passive exercises
D. Choosing a soft mattress and pillow to enhance comfort

51. When assessing a newborn for congestive heart failure, the nurse should observe for the most common sign of:
A. Peripheral edema
B. Distended neck veins
C. Tachycardia
D. Pulmonary edema

52. A 4-year-old boy appears very anxious and frightened before receiving a rectal suppository as a preoperative medication. Which
statement by the nurse would be most appropriate in helping the child take this medication?
A. “Take a nice, big, deep breath and then let me hear you count to five.”
B. “Be a big kid, everyone’s waiting for you.”
C. “Lie still now and I’ll let you have one present before you even have your operation.”
D. “You look so scared. Want to know a secret? This wont hurt a bit!”

53. A nurse in the ER is attending an infant who vomits after every feeding. What appropriate question will the nurse ask the mother to
suspect intussusception?
A. “Is there a blood streak in the vomitus?”
B. “Is the infant manifesting projectile vomiting?”
C. “Is the vomitus dark or coffee ground in color?”
D. “Is there a fecal material in the vomitus?”

54. A mother asks the nurse about the best way to give Nystatin (Mycostatin) suspension to her 6 month old infant with oral thrush.
What will the nurse advice the mother?
A. Mix the suspension with the infant’s formula
B. Dissolve and cover nipple with solution and let baby suck.
C. Ask the physician for the medicine in a different form
D. Place medicine in a baby teaspoon and let the infant swallow together with water

55. Which of these parents' comment for a newborn would most likely reveal an initial finding of a suspected pyloric stenosis?
A. I noticed a little lump a little above the belly button.
B. The baby seems hungry all the time.
C. Vomiting that increases in intensity and shooting across the room
D. Irritation and spitting up immediately after feedings.

56. A child, three months of age, has been admitted with a tentative diagnosis of intussusception. The parent asks the nurse how the
diagnosis is made. Based on an understanding of the diagnostic evaluation for intussusception, what should the nurse say to the
parents?
A. “A small amount of tissue from the colon will be biopsied.”
B. “Genotyping can identify this condition.”
C. “A barium enema will be given to visualize the obstruction.”
D. “An upper GI series should identify the area involved.”

57. Your assessing an infant after repair of a myelomeningocele. What complication is most common after this surgery?
A. Meningitis
B. Hydrocephalus
C. Sepsis
D. Central cyanosis

58. An infant is admitted for surgical repair of gastroschisis. The nurse shows appropriate knowledge on the care of the infant when
she performs the following action preoperatively, except?
A. Wrapping around the exposed bowel with moist saline-soaked pads
B. Use overhead warming unit
C. Perform nasogastric suction
D. Wrapping the abdomen with plastic drapes

59. The nurse is playing with a 2-year-old with Tetralogy of Fallot who suddenly squats on the floor. The best initial nursing action for
the nurse to take is
A. Place the child in the bed and administer oxygen
B. Allow the child to remain in that position and observe him
C. Activate the blue code
D. Bring the child inside the cool mist tent

60. When assessing a 5-year-old child with Duchenne muscular dystrophy (DMD), the nurse evaluates which of the following signs as
indicatng the presence of DMD?
A. One knee is lower when both legs are flexed
B. Truncal asymmetry
C. Mild pain in the hip and anterior thigh
D. Waddling gait

61. A client recently attempted suicide by slashing the wrists. The crisis intervention nurse and physician agree that hospitalization is
not necessary for this client; therefore the nurse needs to:
A. Tell the client to make an appointment soon at the local mental health clinic
B. Wish the client luck and terminate the session
C. Make an appointment the next day and give client a telephone number where the nurse can be reached that night
D. Make an appointment for the client in 2 weeks, when the wrist might be healed

62. Which is the most appropriate response to a client who states emphatically, “I hate them”?
A. “I am here. Tell me more about your hate.”
B. “I will stay with you as long as you feel this way.”
C. “I understand how you can feel this way.”
D. “For whom do you have these feelings?”

63. A 19-year-old college student is admitted to the psychiatric hospital with a diagnosis of schizophrenic reaction. Seven weeks ago
the client began to sleep and eat poorly, was mute for long periods of time, and stayed in the room, grinning and pointing at things.
What should be the first nursing action on admitting the client to the unit?
A. Ask “Do you know where you are?”
B. Take the client to the assigned room
C. Assure the client that “You will be cared for.”
D. Introduce the client to some other clients

64. A doctor asks the nurse to encourage activity by a client who hears voices and is withdrawn and negativistic. What would be the
nurse best approach?
A. Demand that the client join group activity
B. Mention that the “voices” would want the client to participate
C. Tell the client that the nurse needs a partner for an activity
D. Give the client a long explanation of the benefits of the activity

65. A client is placed in isolation because of agitated behavior. The nurse knows it is essential that:
A. All the furniture be removed from the isolation room
B. Restraints be applied
C. The client is allowed to come out after 4 hours
D. A staff member must have a frequent contact with the client

66. A newly admitted 45-year-old woman with obsessive-compulsive behavior frequently removes her shoes. The nurse understands
that the client’s repetitive removing of shoes is probably an attempt to:
A. Control unacceptable impulses or feelings
B. Punish self for guilt feelings
C. Seek attention from the staff
D. Do what the voices the client hears

67. A teenage client has a history of car theft and traffic violations. The home environment has been permissive, and the teenager has
been overly familiar and obsequious with the nurse. A new nurse, about to leave the locked unit, is holding the key as the client
approaches and eagerly offers to unlock the door for the nurse saying, “The other nurses lets me.” Which first response by the nurse
would be most appropriate?
A. Ask the client why he or she wants to unlock the door
B. Let the client turn the key in the lock, but stay close while the client does it
C. Go to the head nurse and ask if it’s all right for the client to unlock the door
D. Tell the client in a nice way that the behavior is not allowed

68. A nurse notices that a client with obsessive-compulsive is frequently washing her feet. The nurse understands that the primary
treatment for a client with obsessive-compulsive behavior is to:
A. Point out the behavior
B. Support but limit the behavior
C. Prohibit the behavior
D. Provide distraction
69. What is the best goal the nurse can expect from a client with Alzheimer’s disease?
A. Hearing will be intact
B. The client is oriented in three spheres
C. The client will not wander off the unit
D. The client can dress himself

70. Which nursing approach would be best for a client with symptoms of severe depression?
A. Ask the client to join the nurse and other clients in the TV lounge
B. Allow the client for quiet thought, remain silent
C. Give the client a choice of recreational activity
D. State that the nurse would like to go with the client for a short walk

Psychiatric 2 - Personality, Somatization, Substance Abuse and Other Disorders


71. When communicating to a grieving family, the emergency nurse should use which of the following forms of communication?
A. Tell the family, “Everything will be all right.”
B. Use words in communicating such as “dead”, “died”, or “death”.
C. Approach the family and tell that the patient did not suffer while he is about to die.
D. Tell the family, “It was for best that the patient died rather than continue suffering”.

72. A client is admitted to the hospital. During the assessment, the nurse notes that the client has not slept for a week. The client is
talking rapidly and throwing his arms around randomly. What would be the highest priority in formulating a nursing care plan for this
client?
A. Isolate the client until he adjusts to the hospital
B. Provide nutritious food and a quiet place to rest
C. Protect the client and others from harm
D. Create a structured environment

73. Which nursing diagnosis would be the priority with a client’s DSM-IV Axis 1 diagnosis of schizophrenia, paranoid type?
A. Altered protection
B. Risk for loneliness
C. Altered thought process
D. Ineffective individual coping

74. A client is scheduled for electroconvulsive therapy (ECT) in the morning. It is not important that the evening nurse ensures that the
client does which of the following?
A. Sign an informed consent
B. Is placed on seizure precaution
C. Remember to take the morning medication
D. has a family member who will bring home any valuables

75. A client is admitted with paranoid schizophrenia. Recognizing the common behaviors exhibited by a client with schizophrenia, the
nurse can anticipate which of the following?
A. Grandiosity, arrogance, and distractability
B. Slumped posture and feelings of despondency
C. Disorientation, anxiety, and panic reactions
D. Withdrawal, regressed behavior, and problems with social skills

76. While caring for a client diagnosed with schizophrenia, the nurse know that the client may have trouble with
A. Staff who are cheerful
B. Simple direct sentences
C. Multistage command
D. Violent behaviors

77. A 28-year-old woman on a psychiatric unit is brought to the emergency department by police. He is on four-point restraints. The
patient was reportedly observed running through the street naked, smashing windows and screaming. She is now calm, nonverbal, and
diaphoretic and has both vertical and horizontal nystagmus. He is noted to have a 2-inch laceration to her arm. What is the priority of
the nurse when assessing this patient?
A. Evaluating his mental status and obtaining a full set of vital signs
B. Performing a primary assessment and rule out other sign of trauma
C. Determining if the patient can cooperate so that restraints can be removed
D. Sending urine specimen for toxicology screening

78. When writing an assessment of a client with mood disorder, the nurse should specify
A. How flat the client’s affect is
B. How suicidal the client is
C. How grandiose the client is
D. How the client is behaving

79. Which nursing diagnosis is most likely to be associated to person with a medical diagnosis of schizophrenia, paranoid type?
A. Impaired social skills related to inadequately developed superego
B. Social isolation related to impaired ability to trust
C. Fear of being alone related to suspiciousness
D. perceptual disturbance related to delusions of persecution
80. A client has been very despondent, withdrawn, and apathetic for about 6 months. Recently, the client began to attend outpatient
clinic for treatment of depressive disorder. Fluoxetine HCL (Prozac) is prescribed, and after 3 days the client shows improvement. What
is the most appropriate nursing intervention at this time?
A. Encourage the client to interact with other clients
B. Assess the client’s knowledge about the medication
C. Evaluate the potential for self-destructive behavior
D. Discuss long term plan for discharge and follow-up

81. A client’s skin test, sputum smear, culture, and chest x-ray are conclusive for tuberculosis. The nurse tells the client that respiratory
isolation will require:
A. Caps and gowns during the period of contagion
B. Both client and attending nurse wearing masks at all times
C. Gloves when handling the client’s tissue, excretions, and linen
D. Nurse and visitors wearing masks, and proper handling of sputum
82. How can RN’s most effectively control transmission of methicillin- resistant Staphylococcus aureus (MRSA)?
A. Place client in total isolation
B. Use gloves and wash hands before and after client contact
C. Use masks and gowns during care of the client with MRSA
D. Do nasal culture on health care workers
83. A client receiving chemotherapy is at risk for bone marrow depression. The nurse instructs the client about how to prevent infection
at home. Client teaching includes which of the following statements?
A. “Get a weekly white blood cell count.”
B. “Wash hands frequently and maintain good hygiene.”
C. “Do not share bathroom with children or pregnant women.”
D. “Avoid contact with others while receiving chemotherapy.”

84. The staff nurse reports that one of the roommates has just been diagnosed with hepatitis A. Which action should be taken?
A. Ask the physician for immune globulin injection
B. Send a stool culture to the lab
C. Decrease protein and carbohydrate intake
D. Assess for jaundice and clay colored urine
85. The infection-control RN visits the staff after a client has been diagnosed with bacterial (meningococcal) meningitis. What
statement by the RN reflects an understanding of the management of this client?
A. A skin culture on macular papular rash should be performed
B. Respiratory isolation is necessary for 24 hours after antibiotics are started
C. Abnormal general muscle contractions are expected
D. Instituting immediate reverse isolation
86. Which of the following is true about caring a patient with Scabies? Select all that apply
A. Mode of transmission: By close personal contact with the infected person or contaminated object
B. Household members and contacts of the infected child needs to be treated at the same time
C. Instruct parents that all clothing, bedding, and pillowcases used by the child need to be changed daily, washed in hot water
with detergent, dried in a hot dryer, and iron before use.
D. Non-washable toys and other items should be sealed in plastic bags for 4 days.
87. When is a contact precaution necessary?
A. Patient came back from SE Asia with yellowish sclerae and pruritus
B. AIDS patient with reddish-brown lesions
C. Patient admitted with suspected meningococcal infection
D. Burn patient about to receive wet to dry dressing

88. A patient is complaining of night sweats and a cough more than two weeks. What other symptoms will the nurse needs to assess to
support the diagnosis of tuberculosis?
A. Weight loss
B. Elevated fever
C. Rhonchi on auscultation
D. Dyspnea
89. A client who is immunocompromised complains of “painful, itchy blisters” on the chest. What should the RN do?
A. Call the physician
B. Use gloves and gowns while assessing the lesions
C. Clarify if the client is on new medication
D. Isolate the client immediately
90. A client with AIDS is afraid of getting toxoplasmosis. The most important precaution to take would be to:
A. Avoid contact with cats and birds
B. Wear a mask when traveling to foreign countries
C. Wear gloves when gardening
D. Wash all vegetables before cooking

91. A client is admitted with hyperthyroidism. In what room would the RN place the client?
A. A room with a client with the same diagnosis
B. Across from the RN’s station
C. A room with a client who had cholecystectomy
D. A private room
92. During a mass disaster who among the patients who need to be discharged to accommodate the incoming pt?
A. A patient, who had undergone endarterectomy the previous day, with a GCS of 15
B. A patient with COPD with an O2 saturation of 93%
C. A patient with DM with glucose reading of 250 mg/dl
D. A child with maculopapular rashes on the trunks and upper extremities
93. Which of the following reflects a true statement regarding informed consent?
A. Withdrawal of the consent should be written and signed by the patient’s witness.
B. Implied consent can be considered during emergency situations and when there is no one to give the consent.
C. Emancipated minor can not legally sign consent until he reaches the age of 18.
D. Withdrawal of consent must be ahead of time and should be approved by the physician.
94. Which of the following constitute a breach of confidentiality?
A. A nurse telling the other nurse that the patient who had a fight with her is about to be discharged.
B. Nurses in the cafeteria talking about the increase in the number of admission of abused patients.
C. Nurses talking about the health management of the patients in the hallway.
D. A nurse observing the patient while the patient reads her chart.
95. Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse make an
exception to this practice?
A. When a family member offers information about their loved one
B. When the client threatens self-harm and harm to others
C. When the health care provider decides the family has a right to know the client's diagnosis
D. When a visitor insists that the visitor has been given permission by the client
96. A client is being treated for paranoid schizophrenia. When the client
became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied.
The nurse's action
A. May result in charges of unlawful seclusion and restraint
B. Leaves the nurse vulnerable for charges of assault and battery
C. Was appropriate in view of the client's history of violence
D. Was necessary to maintain the therapeutic milieu of the unit

97. Which of the following situation constitute a false imprisonment?


A. A nurse placing antiskid pads on an agitated patient on wheelchair
B. A nurse secluding a wandering patient in a room
C. A nurse performing a procedure without consent
D. A nurse threatening to give a medication to a client who continues to be verbally abusive

98. A staff nurse was told by her head nurse to file an incident report. The nurse knows that an incident report is needed when she
commits: SELECT ALL THAT APPLIES
A. Accidental omission of ordered therapies
B. Circumstances that led to injury or risk for client injury
C. Client falls
D. Medication error
E. Needlestick Injury
F. Procedure/Equipment related injuries
G. A visitor having symptoms of an illness
99. Which is not true about incident report?
A. It is used as means of identifying risk situations and improving client care.
B. It should be complete, accurate, and factual.
C. The report is not a substitute for a complete entry in the client’s record regarding the incident.
D. It should be written in the chart that the incident report had been filed.
100. A nurse attending a summer camp for children with medical conditions and disabilities would prioritize which of the following
child?
A. A child with sickle cell anemia who has left upper quadrant pain
B. A child with spina bifida who has musty urine
C. A child with spina bifida who is complaining of headache
D. A child with spina bifida who has a runny nose and cough
101. A charge nurse in the station receives the following telephone call, which telephone call should the charge nurse respond to first?
A. A pediatrician stating that a child will be admitted for an infected circumcision
B. The pharmacy requesting clarification of an IV order
C. The laboratory reporting that a child scheduled for a tonsillectomy has an abnormal bleeding time
D. A staff nurse reporting that a child is in respiratory difficulty and the pediatrician cannot be located
102. Which telephone call from the students’ mothers should the school nurse return to first?
A. A telephone call notifying the school nurse that the child has a temperature of 1020 F and a rash covering the trunk and upper
extremities of the body
B. A telephone call notifying the school nurse that a child underwent an emergency appendectomy during the previous night
C. A telephone call notifying the school nurse that the child’s pediatrician has informed the mother that the child will need cardiac
repair surgery within the next few days
D. A telephone call notifying the school nurse that the child’s pediatrician has informed the mother that the child has head lice
103. A triage nurse must decide which of the following children should be examined first by the pediatrician. Which child would the
triage nurse prioritize?
A. A 5-year-old child with laryngotracheobronchitis who has wheezing on auscultation and a respiratory rate of 30 breaths per
minute
B. A 7-month-old infant who fell from the sofa into the carpeted floor, hitting the head
C. A 4-year-old who fell off a bicycle and has several bleeding lacerations requiring sutures
D. A 6-year-old child experiencing asthma that has diminished wheezing and is very irritable
104. A nurse is planning to conduct a newborn assessment. Upon entering the room, which of the following infants will the nurse need
to attend first?
A. An infant drooling with quiet respirations of 30 breaths per minute
B. An infant jittering with respirations of 55 breaths per minute
C. An infant showing yellowish discoloration of the skin
D. An infant with apnea of 10 seconds
105. Shortly after arriving for the evening shift, the triage nurse evaluates several clients who came in the emergency department.
Which client should receive highest priority?
A. A middle-aged man, diaphoretic and complaining of severe chest pain radiating to the jaw
B. An elderly woman complaining of loss of appetite and fatigue for the past week
C. A basketball player limping and complaining of pain and swelling in the right ankle
D. A housewife with 225 mg/dL glucose complaining of thirst
106. Which client would be the RN’s priority in an acute care situation?
A. A client with diabetes who has a glucose reading of 180
B. A client 3 days postoperative with left calf pain
C. A newly admitted client with chest pain
D. A client who is complaining of pain following surgery from hip pinning
107. The nurse manager has requested a social worker to see the following clients. Which one requires assistance first?
A. A 79-year-old woman, with newly diagnosed stroke, homeless and without any insurance coverage
B. A 55-year-old man, with a history of recent myocardial infarction (MI) who is in the midst of divorce
C. An 89-year-old man with TYPE 2 diabetes and with heart failure and no insurance coverage
D. A 30-year-old woman who is newly diagnosed with HIV and without insurance coverage
108. What are the first nursing actions for a client admitted to the emergency department following an accident?
A. Align the spine, check pupils, and check for hemorrhage
B. Check respirations, circulation, and neurological response
C. Check respirations, stabilize spine, check circulation
D. Assess level of consciousness, circulation
109. What level of prevention is the nurse’s goal in the community following an earthquake?
A. Primary level of prevention
B. Secondary level of prevention
C. Tertiary level of prevention
D. Quaternary level of prevention
110. The nurse has been assigned to these clients in the emergency room. Which client would the nurse go check first?
A. Viral pneumonia with atelectasis
B. Spontaneous pneumothorax with a respiratory rate of 38
C. Tension pneumothorax with slight tracheal deviation to the right
D. Acute asthma with episodes of bronchospasm

111. What patterns reflect the age-related change in taste perception experienced by elderly clients?
A. Use of bland, easily digested food
B. Decreased intake of fluids
C. Increased consumption of salts and sweets
D. Ingestion of more bread, rice, and pasta
112. The best indication of dehydration in a client who is 85 years old would be changes in:
A. Skin turgor
B. Urine output
C. Blood pressure
D. Hemoglobin (Hgb) levels
113. Which of the following symptoms of hyperthyroidism would the nurse expect to find in an elderly client?
A. Palpitations and shortness of breath
B. Nervousness and insomnia
C. Moist skin and fine tremors
D. Anorexia and constipation
114. A nurse conducting a physiologic assessment in an elderly would expect to find the following considered as a normal observation,
except:
A. Diminished gag reflex
B. Senile deafness
C. Increased residual urine and nocturia
D. Increased salivation and diminished sense of taste
115. Which of the following are considered age-related changes in the laboratory findings of an elderly client, except:
A. Increased BUN and creatinine
B. A drop in hemoglobin
C. Increased protein
D. Decreased platelet-release factors
116. A 49y.o. woman is taking supplemental Black Cohosh. The nurse knows that this herbal drug is indicated for the following except:
A. Menopausal symptoms
B. Premenstrual Syndrome
C. Painful Menstruation
D. Irregular Menstruation
117. A patient on Sudafed was assigned to the nurse. When will the nurse intervene?
A. Patient taking Valerian
B. Patient taking Kava-kava
C. Patient taking Ma huang
D. Patient taking Saw Palmetto

118. A patient with insomnia is taking Valerian. The nurse will watch out for the possible side-effect of this drug which is?
A. Hepatotoxic
B. Nephrotoxic
C. Ototoxic
D. Cardiotoxic
119. A patient with Moderate anxiety is taking Kava-Kava. The nurse takes the client history of medications. When will the nurse
intervene?
A. Patient is taking valium
B. Patient is taking MAOI
C. Patient is taking Prozac
D. Patient is taking Ma Huang

120. The nurse is preparing a discharge plan for a patient taking Echinacea. Which of the following is incorrect?
A. It is immune- stimulant
B. It may cause allergic reactions
C. Take it for 12 weeks
D. Use it for colds and URTI

121. Select all that apply to LUNG CANCER:


A. bloody sputum
B. sore throat
C. dysphagia and hoarseness
D. wheezing in the lungs
E. edema of face and neck
F. dyspnea
G. chest pain
122. All of the following are appropriate instructions to a client with metered dose inhaler without spacer, except?
A. Ask the client to inhale and hold breath for 5-10 seconds before removing the inhaler.
B. Hold the inhaler 2 inches away from the open mouth.
C. Instruct the client to place the mouth tightly around the mouthpiece.
D. Allow the client to wait 1-2 minutes before taking another dose.
123. A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that the client
A. Eat foods high in sodium increases sputum liquefaction
B. Use oxygen during meals improves gas exchange
C. Perform exercise after respiratory therapy enhances appetite
D. Cleanse the mouth of dried secretions reduces risk of infection
124. The nurse is performing an assessment on a client with pneumococcal pneumonia. Which finding would the nurse anticipate?
A. Bronchial breath sounds in outer lung fields
B. Decreased tactile fremitus
C. Hacking, nonproductive cough
D. Hyperresonance of areas of consolidation
125. A client had a right lobectomy yesterday and has a chest tube connected to a suction at 20 cm of water pressure. Upon
assessment of the client this morning, the nurse notes that there is no fluctuation in the water-seal chamber. What would be the
nurse’s immediate action?
A. Increase the suction until fluctuation return
B. Order for an immediate x-ray to determine if the lung has re-expanded
C. Check for presence of a dependent loop
D. Elevate the client’s bed to Fowler’s position
126. A client has just returned to the unit after a right pneumonectomy. The nurse’s action shows appropriate understanding about the
surgical procedure when she position the client on his:
A. Left side or back
B. Right side or back
C. Flat on his back
D. Alternating right and left side positions
127. The daily weight for a client with COPD indicates that the client has gained 5lbs in less than a week, even though his oral intake
has been closely monitored. The clients weight gain is associated with what complication?
A. Left ventricular failure
B. Respiratory acidosis
C. Cor pulmonale
D. Pulmonary edema
128. A COPD patient had undergone abdominal surgery. Baseline ABG were obtained and recorded as follows: pH = 7.35; PaO2 = 60;
PaCO2 = 50; HCO3, 25. Following the surgery the nurse documented the following: pH = 7.30; PaO2 = 70; PaCO2 = 55; HCO3 = 23.
Which intervention is most appropriate for the nurse to perform?
A. Instructing deep breathing and coughing techniques
B. Increasing O2 to 4L/m
C. Placing the patient in high Fowler’s position
D. Assist the patient to breath in a paper bag
129. The nurse is caring for a client on oxygen therapy. Which among the Oxygen administration devices deliver the most highest Oxygen
concentration?
A. Partial-Rebreather mask
B. Non-rebreather mask
C. Venturi mask
D. Face Mask
130. A patient with pneumonia has an oxygen saturation of 90%. He is having difficulty in breathing, shallow respirations of 30/min,
crackles and productive coughing. The nurse’s primary concern is to improve respirations and decrease hypoxia. Which would deliver the
most accurate oxygen concentration?
A. Partial Rebreather mask
B. Non-Rebreather mask
C. Venturi mask
D. T-piece

131. In caring for a patient with DVT (Deep Vein Thrombosis), which of the following nursing interventions would be inappropriate?
A. Elevate the foot of the bed
B. Apply elastic stockings to both lower extremities
C. Apply warm, moist heat to the affected extremity
D. Teach patient to use a heel-toe gait when ambulating
132. An 18 month old with Tetralogy of Fallot has a "tet" spell after having an invasive procedure. To improve the child's cardiac status
which of the following interventions should the nurse do initially?
A. Place the child in a knee chest position
B. Begin chest compressions
C. Administer oxygen
D. Position with HOB elevated
133. The nurse is caring for a client who is 3 days post-myocardial infarction (MI). A desired outcome that demonstrates improvement
would be:
A. Adequate vital signs and urinary output
B. Absence of ventricular tachycardia
C. Ability to take brisk walks in hospital corridor
D. Urine output less than 30 cc/hr
134. A client is in the coronary care unit recovery from an acute MI. the nurse should know that 90 percent of all clients with acute MI
develop cardiac dysrhythmias. For which life-threatening dysrhythmias should the nurse be monitoring the client?
A. Ventricular tachycardia
B. Atrial flutter
C. Atrial tachycardia
D. Sinus bradycardia
135. Three hours after admission to the CCU for anterior myocardial infarction (MI), a client develops increasing ventricular ectopy,
followed by a short burst of ventricular tachycardia. The first nursing action is to?
A. Repeat the morphine sulfate, per order
B. Notify the attending physician
C. Increase the flow of oxygen from 4 to 8 liters
D. Administer bolus lidocaine, per order
136. A nurse is conducting health history of a client with a diagnosis of congestive heart failure (CHF). Which of the following questions
would best help the nurse support the diagnosis?
A. “Do you easily get tired after a mild exercise?”
B. “Do you experience leg cramps after walking a few blocks?”
C. “Does your sputum contain a streak of blood?”
D. “Where does the pain radiates?”
137. A client with a history of heart failure would most likely exhibit which of the following symptoms?
A. Crackles and wheezing upon auscultation of the lungs
B. Paradoxical movement of the diaphragm
C. Piercing chest pain and increasing dyspnea
D. Presence of pulsus paradoxus.
138. The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate?
A. Widening pulse pressure
B. Pleural friction rub
C. Distended neck veins
D. Bradycardia
139. An ambulatory client reports edema during the day in his feet and ankles that disappear while sleeping at night. What is the most
appropriate follow-up question for the nurse to ask?
A. "Have you had a recent heart attack?"
B. "Do you become short of breath during your normal daily activities?"
C. "How many pillows do you use at night to sleep comfortably? "
D. "Do you smoke?"
140. The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective
preventive measure?
A. Place pillows under the knees
B. Use elastic stockings continuously
C. Encourage range of motion and ambulation
D. Massage the legs twice daily

141. A patient about to undergo sigmoidoscopy would be appropriately placed in what position?
A. Right side lying with knees flexed
B. Left Lateral with knees flexed
C. Recumbent Position
D. Prone with foot part elevated by pillow
142. Following Total Gastrectomy patients will require vitamin replacement. Of the following, which vitamin is ESSENTIAL and MUST
be given throughout life:
A. Vitamin C
B. Vitamin B6
C. Vitamin D
D. Vitamin B12
143. The nurse knows that the drainage is normal 4 days after sigmoid colostomy when the material is:
A. Solid formed
B. Green liquid
C. Semiformed
D. Loose feces
144. The nurse’s preparation of the client undergoing IV cholangiogram includes:
A. Forcing fluids for 6 to 8 hours before the examination
B. Administering radiopaque tablets the evening before the examination
C. Informing the client about possible reactions when the contrast medium is injected
D. A fatty meal the evening before the examination
145. A client with acute pancreatitis is complaining of numbness with circumoral tingling and muscle cramps. What interventions are
appropriate for these manifestations?
A. Request an order for serum sodium test
B. Assess for hypocalcemia
C. Assess for hypoglycemia
D. Administer potassium IV
146. A client has frequent stools, with poor oral intake of both fluids and solids. While administering the ordered parenteral
hyperalimentation, it is important to remember that hyperalimentation solutions are:
A. Hypertonic solutions used primarily to increase osmotic pressure of blood plasma
B. Hypotonic solutions used primarily for hydration when hemoconcentration is present
C. Hyperosmolar solutions used primarily to reverse negative nitrogen balance
D. Alkalyzing solutions used to treat metabolic acidosis, thus reducing cellular swelling
147. Following Gastric Resection, patients are prone to developing Dumping Syndrome. Which of the following types of dietary intake
by the patient would be MOST helpful to either reduce or prevent this syndrome from developing?
A. Moderate fat, low carbohydrate
B. High fat, high carbohydrate
C. Low fat, low carbohydrate
D. Moderate fat, high carbohydrate
148. A client, admitted 3 days ago fro GI bleeding from a duodenal ulcer, has had a stable vital signs, an Hgb of 13.0, and an Hct of
40. The intervention most likely to help this client at this point is to:
A. Infuse 2 units of packed RBCs over 5 hours
B. Maintain strict bed rest and a calm environment
C. Teach the client about preoperative and postoperative GI surgical care
D. Administer an antibiotic and proton pump inhibitor (Prilosec), if ordered
149. The night RN reports that a client, admitted with a diagnosis of gastric ulcer, is complaining of syncope and vertigo. What is the
initial nursing intervention by the RN?
A. Check the client’s vital signs
B. Keep the client on bed rest
C. Give a stat dose of sucralfate (Carafate)
D. Call for stat Hgb and Hct
150. What is the appropriate nursing action following a liver biopsy?
A. Place the client is supine, in a semi-Fowler’s position
B. Draw blood for a CBC
C. Check vital signs every 15 minutes for 1 hour
D. Place the client on his left side

151. A client was recently diagnosed with hypothyroidism. Nursing assessment would reveal the most common clinical manifestations
of hypothyroidism, which are:
A. Decreased facial expression, diarrhea, and weight gain
B. Increased body temperature, tachycardia, and fatigue
C. Decreased exercise tolerance and facial and pitting edema
D. Increased sluggishness, increased cold intolerance, and puffy eyelids
152. On her first post-partum day, a woman who is diabetic has been eating a full diet, and her insulin was reduced to one-third of the
dosage received during pregnancy. Which sign(s) and/or symptom(s) would indicate that the client is experiencing hyperglycemia?
A. Profuse perspiration
B. Irritability
C. Flushed face
D. Headache
E. rapid pulse
F. Deep, rapid perspirations
153. Which of the following will the nurse caring for a client with Cushing’s syndrome should expect?
A. Skeletal-muscle wasting, because glucocorticoids promote protein and fat mobilization
B. Hypoglycemia due to increased insulin production
C. Discoloration and hyperpigmentation of the skin due to increased pituitary secretion of ACTH
D. Dependent edema and severe hypokalemia due to abnormal aldosterone secretion
154. Appropriate nursing actions for a client with Addison’s disease would include:
A. Administering insulin replacement therapy
B. Reducing physical and emotional stress
C. Providing a low-sodium diet
D. Restricting fluids to 1500 ml/day
155. A newly admitted patient is manifesting irritability, tremors, and weight loss. What laboratory test would the nurse expect?
a. Platelet
b. CBC
c. Thyroxine
d. WBC
156. You are assigned to care for a patient with SIADH (Syndrome of Inappropriate Secretion of Antidiuretic Hormone). In developing
a nursing care plan, which of the following needs would have the highest priority?
A. Oxygenation
B. Nutrition
C. Activity Intolerance
D. Safety
157. Select all that apply to Cushing’s disease signs and symptoms:
A. hypertension
B. amenorrhea and decrease libido
C. hyperglycemia
D. purplish striae
E. hypercalcemia
F. acne
158. A nurse assigned to a post-thyroidectomy patient would prioritize which of the following observation?
A. Complains of fatigue after transferring self to chair
B. Presence of numbness and tingling sensation around the mouth
C. Hoarseness and sore throat
D. Voice weakness
159. A client contacts his home care nurse with complaints of nausea and abdominal pain. He has type 1 diabetes. How should the
nurse advise the client?
A. “Increase your activity level.”
B. “Hold your regular dose of insulin.”
C. “Check your blood glucose level every 3-4 hours.”
D. “Increase your consumption of foods containing simple sugars.”
160. The mother of a boy with type 1 diabetes calls the physician’s office to discuss the child’s self-monitoring blood glucose (SBMG)
home reading. He is being tightly regulated with a combination of NPH and regular insulin before breakfast and supper. The past two
mornings his blood sugar readings were 220 mg/dl and 210 mg/dl. What should the nurse tell the boy’s mother?
A. Check his blood sugar during the night.
B. Continue with his medication regimen.
C. Serve his bedtime snack earlier in the evening.
D. Give his NPH insulin later in the evening.
161. A child on his fifth day admission with acute glomerulonephritis shows the presence of blood and protein in the urinalysis. The
most appropriate action for the nurse is to?
A. Request the laboratory to reanalyze the urine specimen
B. Notify the pediatrician
C. Collect another urine specimen from the child and submit it to the laboratory
D. Note the finding in the chart and file the report in the child’s chart
162. A nurse assigned to a child with Acute Glomerulonephritis is picking up the doctor's orders to be placed in the Kardex. Which of
the orders should the nurse question?
A. Daily blood pressure
B. Daily weights
C. Bed rest
D. Strict I & O
163. A client with a history of Polycystic Kidney Disease is admitted to the Renal Unit for evaluation for dialysis. Which of the following
lab values would be MOST significant in determining renal function?
A. Creatinine 8.7 mg/dl
B. BUN 90 mg/dl
C. Serum K+ 7.0 mEq/l
D. Uric Acid 7.5
164. An 8 year old girl is admitted with R/O Acute Glomerulonephritis. Considering the usual prescribed treatment for this diagnosis,
which would be the earliest clinical manifestation of a response to treatment?
A. Decreased blood pressure
B. Increased urine output
C. Decreased edema
D. Increased serum protein
165. The nurse notices that the weight of a young school-age child hospitalized with acute glomerulonephritis has increased by 1 kg in
the past 3 days. The child’s mother has been bringing in meals from home to encourage the child to eat. The nurse should suspect that
which homemade food most likely has contributed to his weight gain?
A. Hard boiled egg and skimmed milk
B. Chicken soup
C. Pasta and cookies
D. Grilled cheese sandwiches
166. Acute Renal Failure. Write O-oliguric phase, D-diuretic phase, B-both
___ Decrease GFR
___ Increase GFR
___ Hypokalemia
___ Hyperkalemia
___ Hyponatremia
___ Hypovolemia
___ Fluid overload
___ Increase BUN, creatinine
___ Decrease BUN, creatinine
167. The nurse is caring for a patient with ARF. In the diuretic phase of this disease, the nurse will expect the following changes except:
A. Hypokalemia
B. Hypovolemia
C. Hyponatremia
D. Decrease GFR

168. A 69 y.o. Japanese Client with ARF in the oliguric phase of the disease was brought to the hospital. The nurse knows that in order to
be considered oliguric, the urine output of the patient should be?
A. < 200 ml/day
B. < 400 ml/day
C. <600 ml/day
D. <800 ml/day
169. The client’s laboratory result shows BUN 35mg/dL. What should the nurse do?
A. Administer Furosemide stat as ordered.
B. Initiate seizure precautions.
C. Watch out for Respiratory Depression.
D. Monitor LOC closely.
170. Lasix 20 mg IV stat was ordered. The nurse should be cautious in administering this drug in ARF patients because of its many
adverse effects. The primary concern of the nurse is that this drug causes:
A. Nephrotoxicity
B. Hypokalemia
C. Hypocalcemia
D. Circulatory collapse

171. Which change in fluid or electrolyte status would the nurse find is consistent with syndrome of inappropriate antidiuretic hormone
(SIADH)?
A. Urine output of 2500 mL/24 hr
B. Serum sodium of 150 mEq
C. Presence of edema
D. Urine specific gravity of 1.036
172. A 76-year-old man has become overly concerned regarding constipation. The client has abused the use of laxatives and developed
chronic diarrhea. The nurse knows that the client is at risk for which of the following electrolyte imbalance?
A. Azotemia, hyperkalemia, and hyponatremia
B. Bicarbonate excess, hypokalemia, and hypomagnesia
C. Hyperkalemia, hypocalcemia, and hyponatremia
D. Hypomagnesia, hypocalcemia, and hypokalemia
173. A client is admitted with a 72-hour history of nausea and vomiting as a result of severe gastritis. What is the RN’s priority
intervention?
A. Obtain a stool for occult blood
B. Obtain history of diet and medications
C. Start an IV and prepare to give ringer’s lactate
D. Assess for hypokalemia and hypovolemia
174. What assessment finding(s) will the RN expect to see in a client with prerenal kidney failure?
A. Elevated Hct
B. Oliguria with elevated specific gravity
C. Increased BP and pulse
D. Tachypnea and orthopnea
175. The client is started on a regular diet following gastric surgery. The client receives the following for lunch:
8 oz apple juice
½ cup of herb tea
½ turkey sandwich on white bread
½ cup of orange Jello with mandarin oranges
2 cookies
½ cup of cottage cheese
How many milliliters of fluid would be recorded in the intake and output?
________
176. An elderly woman is hospitalized for the treatment of gastroenteritis complicated by dehydration and hyponatremia. The nurse
expects a late symptom of hyponatremia exhibited by the client like
A. Muscle twitches
B. Restlessness
C. Thirst
D. Weakness
177. A client in the acute care facility is irritable but shows within normal vital signs with potassium level of 6.5mEq/L. The nurse caring
the client would alert herself for possible
A. Decrease in cardiac output
B. Cardiac dysrhythmias
C. Reduction in arterial oxygen
D. Pulmonary edema
178. A 65 y.o. patient was rushed in to ER and diagnosed with Toxic Shock Syndrome. The nurse assesses the patient and looks for the
classic sign of TSS which is:
A. maculopapular rash
B. papulovesicular rash
C. pustular rash
D. macular erythroderma
179. Which of the following statements made by by the patient who was rushed in to ER alerts the nurse that the patient has TSS?
A. A sunburn-like rash appeared in my hands yesterday
B. I have a fever of 38oC for 3 days
C. My tongue are very reddish
D. Small tiny dark spots appeared on my chest this morning
180. The nurse caring for a 75. y.o. patient with TSS will be alerted that the client is progressing to septic shock when the patient is
experiencing:
A. Hypotension
B. Tachypnea
C. Tachycardia
D. Confusion

181. Where would the nurse place the call light for a client with a right- sided brain attack and left homonymous hemianopsia?
A. Where the client prefers
B. Directly in front of the client
C. On the client’s left side
D. On the client’s right side
182. A client with seizure disorder is admitted for pneumonia. If the client has a generalized tonic-clonic seizure, what is appropriate
action for the nurse to perform during the seizure episode?
A. Ventilate the client with an “ambu bag” if apneic
B. Move hard objects away from the client’s head
C. Suction secretions
D. Open the mouth to insert oral airway
183. As a result of Guillane-Barre syndrome, a client has a nursing diagnosis of “high risk for disuse.” What intervention would be a
priority to be included in the nursing care plan?
A. Use an air mattress
B. Perform active and passive range-of-motion exercise every 2 hours
C. Turn and reposition client every 2 hours
D. Apply continuous splints to extremities to prevent contractures
184. For a client with multiple sclerosis, what teaching is necessary to prevent fatigue?
A. Avoid extremes of temperature
B. Avoid physical exercise
C. Install safety devices in the home
D. Attend support group meetings
185. Diagnosis of myasthenia gravis is frequently based on the client’s response to an intravenous injection of endrophonium
(Tensilon). If the client responds positively to this drug, the nurse should expect:
A. Relief of ptosis, but not of weakness, in other facial muscles
B. A prompt and dramatic increase in muscle strength
C. Exacerbation of symptomatology
D. A slight increase in muscle strength that is countered by an increase in muscle fatigability
186. In caring for a client with ALS (Amyotrophic Lateral Sclerosis), the nursing diagnosis with the highest priority would be:
A. Impaired Physical Mobility
B. Altered Role Performance
C. Potential for Ineffective Airway Clearance
D. Potential for Impaired Verbal Communication
187. The nurse is caring for a client with an unstable spinal cord injury at the T7 level. Which intervention should take priority in
planning care?
A. Increase fluid intake to prevent dehydration
B. Place client on a pressure reducing support surface
C. Use skin care products designed for use with incontinence
D. Increase caloric intake to aid healing
188. The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect?
A. Confusion
B. Loss of half of visual field
C. Shallow respirations
D. Tonic-clonic seizures
189. A client, age 31, is brought to the emergency room after an automobile accident. She is conscious upon admission. A physical
examination and x-ray reveal a transaction of the spinal cord at T4. The nurse should give highest priority to which of the following?
a) The client has an allergy to iodine.
b) The client has a blood pressure of 110/80
c) The client last voided seven hours ago
d) The client smokes two packs of cigarettes per day
190. A client asks a nurse about some of the causes of migraine headache. Which of the following nurse’s response would not
constitute to the causes of migraines?
a) Changes in weather pattern
b) Sleep pattern changes
c) Menstrual cycle fluctuations
d) Exposure to infection

191. The doctor has ordered ambulation on crutches, with no weight bearing on the affected limb. An appropriate crutch gait for the
nurse to teach the client would be:
A. Two-point gait
B. Three-point gait
C. Four-point gait
D. Tripod gait
192. Following a client’s total hip replacement, what nursing intervention is priority?
A. Initiate passive exercise as soon as possible
B. Turning client to unaffected side with abduction pillow between legs
C. Prevent hip dislocation by maintaining leg adduction using a trocanter roll
D. Provide an overhead trapeze
193. Assessment of a client following a recent fracture of the humerus revealed increasing pain with extension of the fingers of the left
hand. Distal pulse is strong in the limb. Capillary refill is brisk, and there does not appear to be any restriction of the fingers from the
cast. The most likely explanation of the pain is:
A. Disuse syndrome from immobility
B. Possible development of compartment syndrome
C. Compression of nerve at the fracture site
D. Normal response to sudden movement of fingers
194. Immediately on returning to the recovery room, a client’s above-the-knee (AK) amputation stump should initially be:
A. Wrapped in elastic bandage to reduce edema formation
B. Elevate on a the foot of the bed to reduce recurrence of edema and hemorrhage
C. Placed on Buck’s traction to prevent skin and muscle retraction
D. Firmly bandaged to a padded board to prevent contractures

195. To facilitate proper drying of a long leg cast, which measure should the nurse include in the plan of care?
A. Place the client on a bed board.
B. Use only the tips of the fingers to handle the cast.
C. Leave the cast exposed to the air.
D. Encourage the client to remain in one position.
196. Upon a client’s admission for extracapsular fracture of the left femur, the nurse notes that the affected extremity appears:
A. Internally rotated.
B. To have foot-drop.
C. Blanched over the fracture site.
D. Shorter than the other leg.
197. The nurse observes a client in the orthopedic clinic using a long pencil to scratch the skin under the cast. The nurse should:
A. Ask the physician for an oral medication order to relieve itching.
B. Take the Pencil away from the client.
C. Assist the client by gently rolling the casted leg in the palmar surfaces of the nurse’s hands while the client scratches.
D. Explain to the client that scratching under the cast should be avoided, because it may break the skin and cause an infection.
198. A client is admitted to the orthopedic unit with a long leg cast, which is used to immobilize a transverse fracture of the right tibia
fibula. The plaster of paris cast is damp, and the client is complaining that it feels very hot. The nurse should:
A. Tell the client not to worry; this is a common complaint.
B. Explain to the client that the cast will feel hot for several hours as the moisture evaporates and the cast hardens.
C. Recognize that this is a sign of excessive pressure on the soft tissues and notify the physician.
D. Administer Meperidine (Demerol), 50 mg IM, to relieve discomfort.
199. Following an amputation, a nursing measure to help reduce the size of the stump once the surgical wound is healed is:
A. Wrapping moist, warm soaks on the thigh.
B. Elevation of the stump on a pillow when reclining.
C. Applying an elastic bandage.
D. Pushing the stump against a hard surface.
.
200. Which statement correctly describes the four-point gait used when partial weight bearing is permitted?
A. Move both crutches forward together, then swing legs through.
B. Move the right crutch ahead, and then follow with the left foot.
C. Move the left crutch and the right foot forward together.
D. Move both crutches and the weaker leg forward at the same time.

201. A patient with Sickle cell disease is assigned to the nurse. The nurse is to give analgesic to the patient and she knows that she must
avoid giving Demerol because this may induce:
A. Respiratory depression
B. Seizures
C. Sickle cell crisis
D. Hypotension

202. The patient is closely monitored for acute exacerbations of the Sickle cell disease. Which of the ff. phases of this disease poses a life-
threatening crisis which may lead to hypovolemia and shock?
A. Vasoocclusive crisis
B. Splenic sequestration
C. Aplastic Crisis
D. Hematologic crisis
203. Which is the most common type of crisis in Sickle cell disease?
A. Vasoocclusive crisis
B. Splenic sequestration
C. Aplastic Crisis
D. Hematologic crisis
204. The nurse is to perform a Trendelenburg’s test to a patient with Varicose veins. A positive result is:
A. Veins fill from distal end when the client sits.
B. Veins fill from proximal end when the client sits.
C. Veins engorge when the client sits.
D. No veins are seen when the client sits.
205. The nurse and CNA plans their interventions for the day for the client with Peripheral Arterial disease. Which of the ff. should not be
done to the client?
A. Elevate feet at rest to decrease swelling.
B. Provide ROM.
C. Apply warm packs to dilate vessels.
D. Encourage walking
206. The nurse should ask which of the following questions to assess for latex allergy?
A. “Have you experienced working in a health care facility?”
B. “Do you have allergy to citrus fruits?”
C. “What kind of work do you have?”
D. “Are you taking any herbal medicines?”
207. The nurse is caring for a patient with peripheral arterial disease experiencing intermittent claudication. What is the appropriate
intervention to relieve pain?
A. Elevate leg at the level of the heart when sleeping
B. Massage and warm compress every 2- 3 minutes
C. Elevate feet above the heart level
D. Encourage exercise.
208. What will be the correct teaching for patient with SLE?
A. Avoid exposure to sunlight
B. Increase protein in the diet
C. Encourage vigorous exercises
D. Cold treatments for chronic pain in arthritis
209. Within 20 minutes of the start of transfusion, the client develops a sudden fever. The most appropriate initial response by the
nurse is to
A. Force fluids.
B. Continue to monitor the vital signs.
C. Increase the flow rate of IV fluids.
D. Stop the transfusion.
210. The nurse has been teaching an adult who has iron deficiency anemia about those foods that she needs to include in her meal
plans. Which of the following, if selected, would indicate to the nurse that the client understands the dietary instructions?
A. Coffee and tea.
B. Bananas and nuts.
C. Dairy products.
D. Citrus fruits and green leafy vegetables.

211. A client is diagnosed with multiple myeloma. Which of the following should be included in the plan of care?
A. Monitor for hyperkalemia
B. Place in protective isolation
C. Precautions with position changes
D. Administer diuretics as ordered
212. The nurse is caring for a client with benign prostatic hypertrophy. Which of the following assessments would the nurse anticipate
finding?
A. Large volume of urinary output with each voiding
B. Involuntary voiding with coughing and sneezing
C. Frequent urination
D. Urine is dark and concentrated
213. A client has just received the diagnosis of endometrial cancer in its early stage. In taking a nursing history, which of the following
symptoms is most likely to be reported by this client?
A. Uterine enlargement
B. Post menopausal bleeding
C. An abnormal Papanicolaou (Pap) smear
D. Pelvic discomfort
214. A client is receiving combination of chemotherapy for breast cancer. Her most recent complete blood count (CBC) shows the
following: Hgb 12.2, Hct 36%, WBC 2.3/cu mm, and platelets 150,000. Which of the following goals should be given priority by the
nurse in planning care?
A. Maintenance of tissue integrity
B. Prevention of infection
C. Maintenance of tissue perfusion
D. Prevention of bleeding or injury
215. The nurse is caring for a client with cervical cancer. The nurse notes that the radium implant has become dislodged. Which of the
following actions would the nurse take first?
A. Wrap the implant in a blanket and place it behind a lead shield.
B. Stay with the client and contact radiology
C. Obtain a dosimeter reading on the client and report it to the physician
D. Pick up the implant with long-handed forceps and place in a lead container.
216. An elderly has just returned to the nursing unit following a TURP. He has a three-way Foley catheter with CBI connected. He tells
the nurse that he wants to void. The most appropriate action of the nurse is to
A. Notify the physician
B. Irrigate the catheter
C. Allow him to void around the catheter
D. Remove the catheter and assist him to the bathroom
217. The nurse in the medical-surgical unit is monitoring a 55-year-old man who undergoes TURP with a three-way system for bladder
irrigation for possible complications. 24 hours after the surgery the client complains of pain in the surgical area. The nurse would
initially perform which of the following action?
A. Irrigate the tubing system with 50 ml of irrigating solution
B. Check the patency of the catheter tubing
C. Assess for the disconnection of the traction applied to the catheter
D. Administer antispasmodic medication to relieve bladder spasm
218. Which of the following client complains after a removal of catheter for TURP will require immediate follow-up?
A. Erectile dysfunction
B. Dysuria
C. Urinary incontinence
D. Constipation
219. Which of the following instructions should be given to a client regarding testicular self-exam?
A. Perform consistently in the same day of the month
B. You can use a small pen light to illuminate the scrotal sac
C. Palpate the testes immediately after showering
D. Finding a small, pea-like lump is normal
220. Who among the presented clients is at highest risk for colorectal cancer?
A. Patient consuming a high-residue with diverticulosis
B. Patient with rectal polyps and consuming highly refined foods
C. Patient with a diet that includes excessive animal fat
D. Patient working in a rubber factory for more than 20 years
221. A nurse suspects that the patient is experiencing hyperventilation. Which of the following observation will the nurse finds
consistent with her diagnosis of hyperventilation?
A. Increased mental acuity
B. Tracheal deviation
C. Respiratory acidosis
D. Carpopedal spasms
222. A patient was diagnosed of syndrome of inappropriate antidiuretic hormone (SIADH). The nurse would anticipate which of the
following electrolyte imbalance?
A. Potassium
B. Sodium
C. Calcium
D. Magnesium
223. A client is admitted to the unit with potassium level of 2.4 mEq/L. The nurse expects the ECG tracing to show the following
changes, except
A. Tall T wave
B. ST segment depression
C. Prominent U wave
D. Inverted T wave
224. What assessment parameter indicates an effective fluid resuscitation in a client with severe dehydration?
A. Urine output of 30 ml/2 hr
B. Pulse of 95
C. Specific gravity of 1.040
D. Falling CVP readings
225. Which parameter(s) is an important indicator of rapid fluid changes?
A. BUN and Creatinine
B. Weight
C. Skin turgor
D. Temperature
226. A priority nursing intervention for a client with hypervolemia involves:
A. establishing IV access with a large-bore catheter
B. drawing a blood sample for typing and crossmatching
C. monitoring respiratory status for s/s of pulmonary edema
D. encouraging the client to consume sodium-free fluids
227. Rapid administration of hypotonic solutions to a severely dehydrated client should be avoided to prevent which complication?
A. Pulmonary edema
B. Cerebral edema
C. Heart failure
D. Hypotension
228. The nurse has placed her client with hyperkalemia on a cardiac monitor. For which associated ECG abnormalities should the nurse
be alert? SATA
A. Widened QRS
B. Prominent U wave
C. Shortened QT interval
D. Tall, tented T wave
E. Prolonged PR interval
F. Lengthened QT interval
229. Which nursing intervention is most appropriate for a client with hypercalcemia?
A. Ambulate the client as soon as possible
B. Encourage compliance with fluid restrictions
C. Maintain the client on strict bed rest
D. Encourage the consumption of green, leafy, vegetables
230. Signs and symptoms of acute hyperphosphatemia are usually caused by the effects of which electrolyte imbalance?
A. Hypokalemia
B. Hypocalcemia
C. Hypomagnesemia
D. Hypochloremia

231. What time of day would the nurse expect to see signs of hypoglycemia in a client following NPH insulin given at 7:30 am?
A. 8:00 AM to 11:00 AM
B. 2: 00 PM to 5:00 PM
C. 8:00 PM to 11:00 PM
D. 2:00 AM to 5:00 AM
232. A client has been prescribed with tirofiban (Aggrastat) 50 ml to be mixed in a 250 ml bag of sterile normal saline. Which of the
following adverse effect would the nurse needs to watch?
A. Weight gain
B. Paresthesia
C. Melena
D. Diarrhea
233. A patient is on warfarin (Coumadin) therapy. What statement indicates ineffective teaching by the nurse?
A. I need to have my blood checked frequently
B. I can still continue drinking my green tea
C. I need to avoid all forms of NSAIDs
D. I will buy an electric razor for shaving
234. A client with pellagra is prescribed with 500 mg of niacin PO daily. Which of the following observations requires to be reported to
the MD?
A. Dark urine
B. Paresthesia
C. Anorexia
D. Night sweats
235. A nurse would question the MD about the administration of metoprolol (Lopressor) when the patient has?
A. Apical pulse 56 bpm
B. Weight gain of 1 kg for 2 days
C. Blood pressure of 140/100 mmHg
D. respirations of 12 breaths per minute
236. A patient with bipolar disorder who is taking up lithium carbonate (Eskalith) is manifesting tremors. What would be the most
appropriate action for the nurse to take?
A. Hold the next dose and check the lithium level
B. Note the observation in the patient’s chart as this is an expected side effect
C. Stop the drug immediately
D. Continue giving the next dose
237. A nurse understands that which of the following drug group would enhance that ASA side effects and therefore should not be
used together?
A. Anticogulants
B. Aminoglycosides
C. Antibiotics
D. Alkylating agents
238. Which of the following will the nurse identifies as side effects of using lidocaine?
A. Hyperesthesia, depression, palpitations, vomiting
B. Hallucinations, tremor, restlessness, blurring of vision
C. Tachypnea, double vision, diaphoresis, nervousness
D. Hypotension, urine retention, fatigue, dyspnea
239. A client taking alendronate sodium (Fosamax) should be instructed to perform which of the following?
A. Never lie down after intake for atleast 30 minutes
B. Give with antacid
C. Take at bedtime for better absorption
D. Take together with vit C to facilitate absorption
240. The nurse caring the client taking fluphenazine decanoate (Prolixin) should watch the client for
A. Hypertensive crisis
B. Diet restrictions
C. I & O
D. Exposure to sunlight

241. A client taking phenelzine sulfate (Nardil) develops symptoms of upper respiratory infection. The doctor orders pseudoephedrine
HCL (Sudafed). What would be the most appropriate action for the nurse?
A. Withhold the pseudoephedrine HCL
B. Give pseudoephedrine HCL as ordered
C. Ask the doctor to consider other medication
D. Discuss the possible side effects with the client
242. A client is started on haloperidol (Haldol). The nurse will observe for signs of:
A. Parkinsonian symptoms
B. Hypertensive crisis
C. Electrolyte imbalance
D. Liver toxicity
243. Which of the following side effects of lithium carbonate should the nurse prioritized?
A. Fine tremors
B. Nausea and vomiting
C. Decreased level of consciousness
D. Diarrhea
244. A client admitted with a diagnosis of chronic atrial fibrillation is on a daily dose of warfarin (Coumadin) 2.5 mg. the serum
international normalized ratio (INR) level is 4.7. What is the appropriate nursing intervention?
A. Monitor the client for signs of bleeding
B. Prepare to give the client protamine sulfate
C. Observe the client for the possibility of an embolic event
D. Have a PTT drawn to completely evaluate the level of anticoagulation
245. Which outcome is the best indicator that digoxin has been effective?
A. Unlabored respirations and increased urinary output
B. Increased systolic and diastolic blood pressures
C. Increased BP and decreased pulse rate
D. Decreased pulse rate and increased urinary output
246. A client with severe, unstable angina pectoris is started on a nitroglycerin (Nitrostat) drip via IV pump. Which client outcome is
expected from this intervention?
A. Client reports relief of chest pain
B. A decrease of BP to 110/60
C. No evidence of cardiac dysrhythmias
D. An increase of BP to 110/60
247. A client with severe rheumatoid arthritis taking Indomethacin (Indocin) should be instructed to
A. Take the medication with food or antacids
B. Increase in oral fluid intake
C. Take together with NSAID for effective pain relief
D. Take antacid 30 minutes to 1 hour apart
248. Which of the following instructions is not appropriate to give to a patient taking triamcinolone (Kenalog)?
A. Instruct patient to avoid exposure to infections
B. Instruct to take drug with food or milk
C. Notify physician if sudden weight loss occur
D. Do not stop the drug abruptly or without prescriber’s consent
249. A client with influenza type A virus is admitted in the hospital and prescribed with amantadine HCL (Symmetrel) 200 mg PO daily
in a single dose. Which of the following client’s response indicates a need for further teaching about the drug?
A. “I will to move slowly when changing positions or standing.”
B. “I will take the drug before sleep.”
C. “I will notify my doctor if I experience urine retention.”
D. “I will continue taking the drug for 7 days.”
250. The physician has written an order of misoprostol (Cytotec) for the client with NSAID induced ulcers. The client asks the nurse
about the action of the drug and on how does it help her condition. The nurses’ appropriate response would be
A. “Misoprostol (Cytotec) promotes secretion of bicarbonate and cytoprotective mucus.”
B. “Misoprostol (Cytotec) suppresses the secretion of gastric acid produced by the histamine receptors in the stomach.”
C. “Misoprostol (Cytotec) increase the rate of gastric emptying.”
D. “Misoprostol (Cytotec) neutralizes the acidity of the gastric tract.”

251. An elderly client has a history of aortic valve stenosis. Identify the area where the nurse should place the stethoscope to best hear
the murmur.
252. A nurse is assisting a client with right-sided weakness from the chair to the bathroom.
Which illustration demonstrates proper positioning for a nurse to assist?

253. The nurse is assessing a client’s respiratory pattern. Which graphic illustrates
Kussmaul’s respirations?

254. A client with sepsis and hypotension is being treated with dopamine hydrochloride. A nurse asks a colleague to double-check the
dosage that the client is receiving. The 250-ml bag contains 400 mg of dopamine, the infusion pump is running at 23 ml/hour, and the
client weighs 80 kg. How many micrograms per kilogram per minute is the client receiving? Record your answer using one decimal
point.
_________________________________ μg/kg/minute

255. The nurse is evaluating an electrocardiogram (ECG) tracing. Which graphic shows the QT interval?

256. A nurse is caring for a client with Raynaud’s phenomenon secondary to systemic lupus
erythematosus (SLE). Which of the client statements shows an understanding of the nurse’s teaching about this disorder? Select all
that apply.
a. “My hands get pale, bluish, and feel numb and painful when I’m really stressed.”
b. “I can’t continue to wash dishes and do my cleaning because of this problem.”
c. “I don’t need to report any other skin problems with my fingers or hands to my practitioner.”
d. “I probably got this disorder because I have lupus.”
e. “This problem is caused by a temporary lack of circulation in my hands.”
f. “Medication might help treat this problem.”

257. A nurse is evaluating the 12-lead ECG of a client experiencing an inferior wall myocardial infarction (MI). While conferring with the
heath care team, which ECG changes associated with an evolving MI does the nurse correctly identify? Select all that apply.
a. Notched T wave
b. Presence of a U wave
c. T-wave inversion
d. Prolonged PR interval
e. ST-segment elevation
f. Pathologic Q wave
258. A nurse places electrodes on a collapsed individual who was visiting a hospitalized family member, the monitor exhibits the
following. Which interventions should the nurse do first?

a. Place the client on oxygen.


b. Confirm the rhythm with a 12-lead ECG.
c. Administer amiodarone (Cordarone) I.V. as prescribed.
d. Assess the client’s airway, breathing, and circulation.

259. A nurse is evaluating a client with primary pulmonary hypertension for a heart–lung transplant. Which medication treatment would
the nurse anticipate to be included in the plan of care? Select all that apply.
a. Oxygen therapy
b. Aminoglycosides
c. Diuretics
d. Vasodilators
e. Antihistamines
f. Sulfonamides

260. A nurse is caring for a client with history of heart failure and presenting with a PE. The nurse documents admission findings of
sudden shortness of breath, chest pain, and immobility. Which nursing diagnoses are admission priorities? Select all that apply.
a. Activity intolerance related to inadequate oxygenation.
b. Anxiety related to breathlessness.
c. Disturbed sleep pattern related to inability to assume recumbent position.
d. Ineffective breathing pattern related to hypoxia.
e. Risk for decreased cardiac output related to failure of the left ventricle.
f. Social isolation related to hospitalization.

261. A nurse is caring for a client with pulmonary edema whose respiratory status is declining.
Chronologically arrange the nursing interventions to prioritize care. Use all the options.
a. Administer oxygen via nasal cannula at 2 L/minute.
b. Call the physician.
c. Prepare suctioning equipment at the bedside.
d. Position the client upright at a 45° angle.
e. Administer furosemide (Lasix) 40 mg I.V. STAT.
f. Insert an indwelling urinary catheter.

262. A nurse is providing discharge instructions on phenytoin (Dilantin) to a female client with tonic-clonic seizure disorder. Which
instructions should the nurse include? Select all that apply.
a. Monitor the body for any skin rash.
b. Maintain adequate amounts of fluid and fiber in the diet.
c. Perform good oral hygiene, including daily brushing and flossing.
d. Receive necessary periodic blood work.
e. Report any problems with walking or coordination, slurred speech, or nausea.
f. Feel safe about taking this drug, even during pregnancy.

263. A nurse is preparing to administer phenytoin (Dilantin) to a 99 lb client with a seizure disorder. The medication administration
record documents phenytoin 5 mg/kg/day to be administered in three divided doses. How many milligrams of phenytoin should be
administered in the first dose? Record your answer as a whole number.
__________________________________________ mg

264. A nurse is comparing the neurological status of a client who suffered a head injury with the status on the previous shift. Using the
Glasgow Coma Scale, the nurse determines that the client’s score has changed from 11 to 15. Which of the following responses did the
nurse assess in this client? Select all that apply.
a. Spontaneous eye opening.
b. Tachypnea, bradycardia, and hypotension.
c. Unequal pupil size.
d. Orientation to person, place, and time.
e. Pain localization.
f. Incomprehensible sounds.

265. A nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis
above T5, and blood pressure of 162/96 mm Hg. The client reports a severe, pounding headache. Which nursing interventions would
be appropriate for this client? Select all that apply.
a. Elevate the head of the bed to 90°.
b. Loosen constrictive clothing.
c. Use a fan to reduce diaphoresis.
d. Assess for bladder distention and bowel impaction.
e. Administer antihypertensive medication.
f. Place the client in a supine position with legs elevated.