Practice Exam 1 Questions

The nurse is assisting in the care of a patient with diverticulosis. Which of the following assessment findings would necessitate a report to the doctor? ❍ A. Bowel sounds of 5-20 seconds ❍ B. Intermittent left lower-quadrant pain ❍ C. Constipation alternating with diarrhea ❍ D. Hemoglobin 26% and hematocrit 32

Low hemoglobin and hematocrit might indicate intestinal bleeding. Answers A, B, and C are normal lab values.

The nurse is taking the blood pressure of an obese client. If the blood pressure cuff is too small, the results will be: ❍ A. A false elevation ❍ B. A false low reading ❍ C. A blood pressure reading that is correct ❍ D. A subnormal finding

Answer A is correct. If the blood pressure cuff is too small, the result will be a blood pressure that is a false elevation. Answers B, C, and D are incorrect. If the blood pressure cuff is too large, a false low will result. Answers C and D have basically the same meaning.

The client has a prescription for a calcium carbonate compound to neutralize stomach acid. The nurse should assess the client for: ❍ A. Constipation ❍ B. Hyperphosphatemia ❍ C. Hypomagnesemia ❍ D. Diarrhea

Answer A is correct. The client taking calcium preparations will frequently develop constipation so the client should be assessed for any problems related to bowel elimination. Answers B, C, and D are not problems related to the use of calcium carbonate.

Which laboratory test would be the least effective in making the diagnosis of a myocardial infarction? ❍ A. AST ❍ B. Troponin ❍ C. CK-MB ❍ D. Myoglobin

Answer A is correct. Answer A, AST, is not specific for myocardial infarction. Troponin, CK-MB, and myoglobin, in answers B, C, and D, are more specific, although myoglobin is also elevated in burns and trauma to muscles.

A client who has been receiving urokinase has a large bloody bowel movement. What nursing action would be best for the nurse to take immediately? ❍ A. Administer vitamin K IM ❍ B. Discontinue the urokinase ❍ C. Reduce the urokinase and administer heparin ❍ D. Stop the urokinase, notify the physician, and prepare to administer amicar

Answer D is correct. Urokinase is a thrombolytic used to destroy a clot following a myocardial infraction. If the client exhibits overt signs of bleeding, the nurse should stop the medication, call the doctor immediately, and prepare the antidote, which is Amicar. Answer B is not correct because simply stopping the urokinase is not enough. In answer A, vitamin K is not the antidote for urokinase, and reducing the urokinase, as stated in answer B, is not enough.

A 4-year-old with cystic fibrosis has a prescription for Viokase pancreatic enzymes to prevent malabsorption. The correct time to give pancreatic enzyme is: ❍ A. 1 hour before meals ❍ B. 2 hours after meals ❍ C. With each meal and snack ❍ D. On an empty stomach

Answer C is correct. Viokase is a pancreatic enzyme that is used to facilitate digestion. It should be given with meals and snacks, and it works well in foods such as applesauce. Answers A, B, and D are incorrect times to administer this medication.

A 5-year-old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery? ❍ A. Decreased appetite ❍ B. A low-grade fever ❍ C. Chest congestion ❍ D. Constant swallowing

Answer D is correct. A complication of a tonsillectomy is bleeding, and constant swallowing may indicate bleeding. Decreased appetite is expected after a tonsillectomy, as is a low-grade temperature; thus, answers A and B are incorrect. In answer C, chest congestion is not normal but is not associated with the tonsillectomy.

The nurse has just received a change-of-shift report. Which clientshould the nurse assess first? ❍ A. A client 2 hours post-lobectomy with 150ccs drainage ❍ B. A client 2 days post-gastrectomy with scant drainage ❍ C. A client with pneumonia with an oral temperature of 102°F ❍ D. A client with a fractured hip in Buck's traction

Answer A is correct. The first client to be seen is the one who recently returned from surgery. The other clients in answers B, C, and D are more stable and can be seen later.

A client is being monitored using a central venous pressure monitor. If the pressure is 2cm of water, the nurse should: ❍ A. Call the doctor immediately ❍ B. Slow the intravenous infusion ❍ C. Listen to the lungs for rales ❍ D. Administer a diuretic

Answer A is correct. The normal central venous pressure is 5-10cm of water. A reading of 2cm is low and should be reported. Answers B, C, and D indicate that the nurse believes that the reading is too high and is incorrect.

The doctor is preparing to remove chest tubes from the client's left chest. In preparation for the removal, the nurse should instruct the client to: ❍ A. Breathe normally ❍ B. Hold his breath and bear down ❍ C. Take a deep breath ❍ D. Sneeze on command

Answer B is correct. The client should be asked to perform Valsalva maneuver while the chest tube is being removed. This prevents changes in pressure until an occlusive dressing can be applied. Answers A and C are not recommended, and sneezing is difficult to perform on command.

The physician prescribes regular insulin, 5 units subcutaneous. Regular insulin begins to exert an effect: ❍ A. In 5-10 minutes ❍ B. In 10-20 minutes ❍ C. In 30-60 minutes ❍ D. In 60-120 minutes

Answer C is correct. The time of onset for regular insulin is 30-60 minutes; therefore, answers A, B, and D are incorrect.

Six hours after birth, the infant is found to have an area of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as: ❍ A. A cephalohematoma ❍ B. Molding ❍ C. Subdural hematoma ❍ D. Caput succedaneum

Answer A is correct. A swelling over the right parietal area is a cephalohematoma, an area of bleeding outside the cranium. This type of hematoma does not cross the suture line because it is outside the cranium but beneath the periosteum. Answer B, molding, is overlapping of the bones of the cranium and, thus, incorrect. In answer C, a subdural hematoma, or intracranial bleeding, is ominous and can be seen only on a CAT scan or x-ray. A caput succedaneum, in answer D, crosses the suture line and is edema.

The client is scheduled for a Tensilon test to check for Myasthenia Gravis. Which medication should be kept available during the test? ❍ A. Atropine sulfate ❍ B. Furosemide ❍ C. Prostigmin ❍ D. Promethazine

Answer A is correct. Atropine sulfate is the antidote for Tensilon and is given to treat cholenergic crises. Furosemide (answer B) is a diuretic, Prostigmin (answer C) is the treatment for myasthenia gravis, and Promethazine (answer D) is an antiemetic, antianxiety medication. Thus, answers B, C, and D are incorrect.

The nurse is assigned to care for an infant with physiologic jaundice. Which action by the nurse would facilitate elimination of the bilirubin? ❍ A. Increasing the infant's fluid intake ❍ B. Maintaining the infant's body temperature at 98.6°F ❍ C. Minimizing tactile stimulation ❍ D. Decreasing caloric intake

Answer A is correct. Bilirubin is excreted through the kidneys, thus the need for increased fluids. Maintaining the body temperature is important but will not assist in eliminating bilirubin; therefore, answer B is incorrect. Answers C and D are incorrect because they do not relate to the question.

The client is admitted for evaluation of aggressive behavior and diagnosed with antisocial personality disorder. A key part of the care of such a client is: ❍ A. Setting realistic limits ❍ B. Encouraging the client to express remorse for behavior ❍ C. Minimizing interactions with other clients ❍ D. Encouraging the client to act out feelings of rage

Answer A is correct. Clients with antisocial personality disorder must have limits set on their behavior because they are artful in manipulating others. Answer B is not correct because they do express feelings and remorse. Answers C and D are incorrect because it is unnecessary to minimize interactions with others or encourage them to act out rage more than they already do.

The nurse is caring for a client with cerebral palsy. The nurse should provide frequent rest periods because: ❍ A. Grimacing and writhing movements decrease with relaxation and rest. ❍ B. Hypoactive deep tendon reflexes become more active with rest. ❍ C. Stretch reflexes are increased with rest. ❍ D. Fine motor movements are improved.

Answer A is correct. Frequent rest periods help to relax tense muscles and preserve energy. Answers B, C, and D are incorrect because they are untrue statements.

The client arrives in the emergency room with a hyphema. Which action by the nurse would be best? ❍ A. Elevate the head of the bed and apply ice to the eye ❍ B. Place the client in a supine position and apply heat to the knee ❍ C. Insert a Foley catheter and measure the intake and output ❍ D. Perform a vaginal exam and check for a discharge

Answer A is correct. Hyphema is blood in the anterior chamber of the eye and around the eye. The client should have the head of the bed elevated and ice applied. Answers B, C, and D are incorrect and do not treat the problem.

A new nursing graduate indicates in charting entries that he is a licensed practical nurse, although he has not yet received the results of the licensing exam. The graduate's action can result in what type of charge: ❍ A. Fraud ❍ B. Tort ❍ C. Malpractice ❍ D. Negligence

Answer A is correct. Identifying oneself as a nurse without a license defrauds the public and can be prosecuted. A tort is a wrongful act; malpractice is failing to act appropriately as a nurse or acting in a way that harm comes to the client; and negligence is failing to perform care. Therefore, answers B, C, and D are incorrect.

If the nurse is unable to illicit the deep tendon reflexes of the patella, the nurse should ask the client to: ❍ A. Pull against the palms ❍ B. Grimace the facial muscles ❍ C. Cross the legs at the ankles ❍ D. Perform Valsalva maneuver

Answer A is correct. If the nurse cannot elicit the patella reflex (knee jerk), the client should be asked to pull against the palms. This helps the client to relax the legs and makes it easier to get an objective reading. Answers B, C, and D will not help with the test.

The nurse on the 3-11 shift is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in the morning and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action? ❍ A. Call the surgeon and ask him or her to see the client to clarify the information ❍ B. Explain the procedure and complications to the client ❍ C. Check in the physician's progress notes to see if understanding has been documented ❍ D. Check with the client's family to see if they understand the procedure fully

Answer A is correct. It is the responsibility of the physician to explain and clarify the procedure to the client. Answers B, C, and D are incorrect because they are not within the nurse's purview

The client is admitted with a BP of 210/120. Her doctor orders furosemide (Lasix) 40mg IV stat. How should the nurse administer the prescribed furosemide to this client? ❍ A. By giving it over 1-2 minutes ❍ B. By hanging it IV piggyback ❍ C. With normal saline only ❍ D. By administering it through a venous access device

Answer A is correct. Lasix should be given approximately 1mL per minute to prevent hypotension. Answers B, C, and D are incorrect because it is not necessary to be given in an IV piggyback, with saline, or through a venous access device (VAD).

Shortly after the client was admitted to the postpartum unit, the nurse notes heavy lochia rubra with large clots. The nurse should anticipate an order for: ❍ A. Methergine ❍ B. Stadol ❍ C. Magnesium sulfate ❍ D. Phenergan

Answer A is correct. Methergine is a drug that causes uterine contractions. It is used for postpartal bleeding that is not controlled by Pitocin. Answers B, C, and D are incorrect: Stadol is an analgesic; magnesium sulfate is used for preeclampsia; and phenergan is an antiemetic.

When assessing a client for risk of hyperphosphatemia, which piece of information is most important for the nurse to obtain? ❍ A. A history of radiation treatment in the neck region ❍ B. A history of recent orthopedic surgery ❍ C. A history of minimal physical activity ❍ D. A history of the client's food intake

Answer A is correct. Previous radiation to the neck might have damaged the parathyroid glands, which are located on the thyroid gland, and interfered with calcium and phosphorus regulation. Answer B has no significance to this case; answers C and D are more related to calcium only, not to phosphorus regulation.

A new diabetic is learning to administer his insulin. He receives 10U of NPH and 12U of regular insulin each morning. Which of the following statements reflects understanding of the nurse's teaching? ❍ A. "When drawing up my insulin, I should draw up the regular insulin first." ❍ B. "When drawing up my insulin, I should draw up the NPH insulin first." ❍ C. "It doesn't matter which insulin I draw up first." ❍ D. "I cannot mix the insulin, so I will need two shots."

Answer A is correct. Regular insulin should be drawn up before the NPH. They can be given together, so there is no need for two injections, making answer D incorrect. Answer B is obviously incorrect, and answer C is incorrect because it does matter which is drawn first: Contamination of NPH into regular insulin will result in a hypoglycemic reaction at unexpected times.

The nurse is caring for a client scheduled for removal of the pituitary gland. The nurse should be particularly alert for: ❍ A. Nasal congestion ❍ B. Abdominal tenderness ❍ C. Muscle tetany ❍ D. Oliguria

Answer A is correct. Removal of the pituitary gland is usually done by a transphenoidal approach, through the nose. Nasal congestion further interferes with the airway. Answers B, C, and D are not correct because they are not directly associated with the pituitary gland.

A client in the cardiac step-down unit requires suctioning for excess mucous secretions. The nurse should be most careful to monitor the client for which dysrhythmia during this procedure? ❍ A. Bradycardia ❍ B. Tachycardia ❍ C. Premature ventricular beats ❍ D. Heart block

Answer A is correct. Suctioning can cause a vagal response and bradycardia. Answer B is unlikely and, therefore, not most important, although it can occur. Answers C and D can occur as well, but they are less likely.

The client arrives in the emergency room with a "bull's eye" rash. Which question would be most appropriate for the nurse to ask the client? ❍ A. "Have you found any ticks on your body?" ❍ B. "Have you had any nausea in the last 24 hours?" ❍ C. "Have you been outside the country in the last 6 months?" ❍ D. "Have you had any fever for the past few days?"

Answer A is correct. The "bull's eye" rash is indicative of Lyme's disease, a disease spread by ticks. The signs and symptoms include elevated temp-erature, headache, nausea, and the rash. Although answers B and D are important, the question asks which would be best. Answer C has no significance.

The doctor has ordered antithrombolic stockings to be applied to the legs of the client with peripheral vascular disease. The nurse knows that the proper method of applying the stockings is: ❍ A. Before rising in the morning ❍ B. With the client in a standing position ❍ C. After bathing and applying powder ❍ D. Before retiring in the evening

Answer A is correct. The best time to apply antithrombolytic stockings is in the morning before rising. If the doctor orders them later in the day, the client should return to bed, wait 30 minutes, and apply the stockings. Answers B, C, and D are incorrect because there is likely to be more peripheral edema if the client is standing or has just taken a bath; before retiring in the evening is wrong because, late in the evening, more peripheral edema will be present.

While caring for a client with hypertension, the nurse notes the following vital signs: BP of 140/20, pulse 120, respirations 36, temperature 100.8°F. The nurse's initial action should be to: ❍ A. Call the doctor ❍ B. Recheck the vital signs ❍ C. Obtain arterial blood gases ❍ D. Obtain an ECG

Answer A is correct. The client is exhibiting a widened pulse pressure, tachycardia, and tachypnea. The next action after obtaining these vital signs is to notify the doctor for additional orders. Rechecking the vitals signs, as in answer B, is wasting time. It is the doctor's call to order arterial blood gases and an ECG.

A client with an abdominal aortic aneurysm is admitted in preparation for surgery. Which of the following should be reported to the doctor? ❍ A. An elevated white blood cell count ❍ B. An abdominal bruit ❍ C. A negative Babinski reflex ❍ D. Pupils that are equal and reactive to light

Answer A is correct. The elevated white blood cell count should be reported because this indicates infection. A bruit will be heard if the client has an aneurysm, and a negative Babinski is normal in the adult, as are pupils that are equal and reactive to light and accommodation; thus, answers B, C, and D are incorrect.

The nurse is caring for the client with a mastectomy. Which action would be contraindicated? ❍ A. Taking the blood pressure in the side of the mastectomy ❍ B. Elevating the arm on the side of the mastectomy ❍ C. Positioning the client on the unaffected side ❍ D. Performing a dextrostix on the unaffected side

Answer A is correct. The nurse should not take the blood pressure on the affected side. Also, venopunctures and IVs should not be used in the affected area. Answers B, C, and D are all indicated for caring for the client. The arm should be elevated to decrease edema. It is best to position the client on the unaffected side and perform a dextrostix on the unaffected side

The nurse is making assignments for the day. Which client should be assigned to the pregnant nurse? ❍ A. The client receiving linear accelerator radiation therapy for lung cancer ❍ B. The client with a radium implant for cervical cancer ❍ C. The client who has just been administered soluble brachytherapy for thyroid cancer ❍ D. The client who returned from placement of iridium seeds for prostate cancer

Answer A is correct. The pregnant nurse should not be assigned to any client with radioactivity present. Therefore, the client receiving linear accelerator therapy is correct because this client travels to the radium department for therapy, and the radiation stays in the department; the client is not radioactive. The client in answer B does pose a risk to the pregnant client. The client in answer C is radioactive in very small doses. For approximately 72 hours, the client should dispose of urine and feces in special containers and use plastic spoons and forks. The client in answer D is also radioactive in small amounts, especially upon return from the procedure.

A 24-year-old female client is scheduled for surgery in the morning. Which of the following is the primary responsibility of the nurse? ❍ A. Taking the vital signs ❍ B. Obtaining the permit ❍ C. Explaining the procedure ❍ D. Checking the lab work

Answer A is correct. The primary responsibility of the nurse is to take the vital signs before any surgery. The actions in answers B, C, and D are the responsibility of the doctor and, therefore, are incorrect for this question.

The graduate licensed practical nurse is assigned to care for the client on ventilator support, pending organ donation. Which goal should receive priority? ❍ A. Maintain the client's systolic blood pressure at 70mmHg or greater ❍ B. Maintain the client's urinary output greater than 300cc per hour ❍ C. Maintain the client's body temperature of greater than 33°F rectal ❍ D. Maintain the client's hematocrit less than 30%

Answer A is correct. When the cadaver client is being prepared to donate an organ, the systolic blood pressure should be maintained at 70mmHg or greater to ensure a blood supply to the donor organ. Answers B, C, and D are incorrect because they are unnecessary actions for organ donation.

In terms of cognitive development, a 2-year-old would be expected to: ❍ A. Think abstractly ❍ B. Use magical thinking ❍ C. Understand conservation of matter ❍ D. See things from the perspective of others

Answer B is correct. A 2-year-old is expected only to use magical thinking, such as believing that a toy bear is a real bear. Answers A, C, and D are not expected until the child is much older. Abstract thinking, conservation of matter, and the ability to look at things from the perspective of others are not skills for small children.

The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs. Which equipment should be kept at the bedside? ❍ A. A pair of forceps ❍ B. A torque wrench ❍ C. A pair of wire cutters ❍ D. A screwdriver

Answer B is correct. A torque wrench is kept at the bedside to tighten and loosen the screws of crutchfield tongs. This wrench controls the amount of pressure that is placed on the screws. A pair of forceps, wire cutters, and a screwdriver, in answers A, C, and D, would not be used and, thus, are incorrect.

The nurse is caring for a client with a malignancy. The classification of the primary tumor is Tis. The nurse should plan care for a tumor: ❍ A. That cannot be assessed ❍ B. That is in situ ❍ C. With increasing lymph node involvement ❍ D. With distant metastasis

Answer B is correct. Cancer in situ means that the cancer is still localized to the primary site. Cancer is graded in terms of tumor, grade, node involvement, and mestatasis. Answer A is incorrect because it is an untrue statement. Answer C is incorrect because T indicates tumor, not node involvement. Answer D is incorrect because a tumor that is in situ is not metastasized.

The nurse is obtaining a history of an 80-year-old client. Which statement made by the client might indicate a possible fluid and electrolyte imbalance? ❍ A. "My skin is always so dry." ❍ B. "I often use a laxative for constipation." ❍ C. "I have always liked to drink a lot of ice tea." ❍ D. "I sometimes have a problem with dribbling urine."

Answer B is correct. Frequent use of laxatives can lead to diarrhea and electrolyte loss. Answers A, C, and D are not of particular significance in this case and, therefore, are incorrect.

The client is receiving peritoneal dialysis. If the dialysate returns cloudy, the nurse should: ❍ A. Document the finding ❍ B. Send a specimen to the lab ❍ C. Strain the urine ❍ D. Obtain a complete blood count

Answer B is correct. If the dialysate returns cloudy, infection might be present and must be evaluated. Documenting the finding, as stated in answer A, as not enough; straining the urine, in answer C, is incorrect; and dialysate, in answer D, is not urine at all. However, the physician might order a white blood cell count

When the nurse is gathering information for the assessment, the patient states, "My stomach hurts about 2 hours after I eat." Based upon this information, the nurse knows the patient likely has a: ❍ A. Gastric ulcer ❍ B. Duodenal ulcer ❍ C. Peptic ulcer ❍ D. Curling's ulcer

Answer B is correct. Individuals with ulcers within the duodenum typically complain of pain occurring 2-3 hours after a meal, as well as at night. The pain is usually relieved by eating. The pain associated with gastric ulcers, answer A, occurs 30 minutes after eating. Answer C is too vague and does not distinguish the type of ulcer. Answer D is associated with stress.

The nurse is preparing a client for surgery. Which item is most important to remove before sending the client to surgery? ❍ A. Hearing aid ❍ B. Contact lenses ❍ C. Wedding ring ❍ D. Artificial eye

Answer B is correct. It is most important to remove the contact lenses because leaving them in can lead to corneal drying, particularly with contact lenses that are not extended-wear lenses. Leaving in the hearing aid or artificial eye will not harm the client. Leaving the wedding ring on is also allowed; usually, the ring is covered with tape. Therefore, answers A, C, and D are incorrect.

Lidocaine is a medication frequently ordered for the client experiencing: ❍ A. Atrial tachycardia ❍ B. Ventricular tachycardia ❍ C. Heart block ❍ D. Ventricular brachycardia

Answer B is correct. Lidocaine is used to treat ventricular tachycardia. This medication slowly exerts an antiarrhythmic effect by increasing the electric stimulation threshold of the ventricles without depressing the force of ventricular contractions. It is not used for atrial arrhythmias; thus, answer A is incorrect. Answers C and D are incorrect because it slows the heart rate, so it is not used for heart block or brachycardia.

The nurse is assisting in the assessment of the patient admittedwith abdominal pain. Why should the nurse ask about medications that the client is taking? ❍ A. Interactions between medications can be identified. ❍ B. Various medications taken by mouth can affect the alimentary tract. ❍ C. This will provide an opportunity to educate the patient regarding the medications used. ❍ D. The types of medications might be attributable to an abdominal pathology not already identified.

Answer B is correct. Many medications can irritate the stomach and contribute to abdominal pain. For answer A, the primary reason for asking about medications is not to identify interactions between medication. Although this might provide an opportunity for teaching, this is not the best time to teach. Therefore, answers C and D are incorrect.

Several clients are admitted to the emergency room following a three-car vehicle accident. Which clients can be assigned to share a room in the emergency department during the disaster? ❍ A. The schizophrenic client having visual and auditory hallucinations and the client with ulcerative colitis ❍ B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm ❍ C. A child whose pupils are fixed and dilated and his parents, and the client with a frontal head injury ❍ D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain

Answer B is correct. Out of all of these clients, it is best to hold the pregnant client and the client with a broken arm and facial lacerations in the same room. The clients in answer A need to be placed in separate rooms because these clients are disruptive or have infections. In the case of answer C, the child is terminal and should be in a private room with his parents.

A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include which statement in the teaching session? ❍ A. "You will be sitting for the examination procedure." ❍ B. "Portions of the procedure will cause pain or discomfort." ❍ C. "You will be given some medication to anesthetize the area." ❍ D. "You will not be able to drink fluids for 24 hours before the study."

Answer B is correct. Portions of the exam are painful, especially when the sample is being withdrawn, so this should be included in the session with the client. Answer A is incorrect because the client will be positioned prone, not in a sitting position, for the exam. Anesthesia is not commonly given before this test, making answer C incorrect. Answer D is incorrect because the client can eat and drink following the test.

The doctor has ordered a Transcutaneous Electrical Nerve Stimulation (TENS) unit for the client with chronic back pain. The nurse teaching the client with a TENS unit should tell the client: ❍ A. "You may be electrocuted if you use water with this unit." ❍ B. "Please report skin irritation to the doctor." ❍ C. "The unit may be used anywhere on the body without fear of adverse reactions." ❍ D. "A cream should be applied to the skin before applying the unit."

Answer B is correct. Skin irritation can occur if the TENS unit is used for prolonged periods of time. To prevent skin irritations, the client should change the location of the electrodes often. Electrocution is not a risk because it uses a battery pack; thus, answer A is incorrect. Answer C is incorrect because the unit should not be used on sensitive areas of the body. Answer D is incorrect because no creams are to be used with the device.

Which information should be reported to the state Board of Nursing? ❍ A. The facility fails to provide literature in both Spanish and English. ❍ B. The narcotic count has been incorrect on the unit for the past 3 days. ❍ C. The client fails to receive an itemized account of his bills and services received during his hospital stay. ❍ D. The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath.

Answer B is correct. The Joint Commission on Accreditation of Hospitals will probably be interested in the problems in answers A and C. The failure of the nursing assistant to assist the client with hepatitis should be reported to the charge nurse. If the behavior continues, termination may result. Answer D is incorrect because failure to feed and bathe the client should be reported to the superior, not the Board of Nursing.

The nurse overhears the patient care assistant speaking harshly to the client with dementia. The charge nurse should: ❍ A. Change the nursing assistant's assignment ❍ B. Explore the interaction with the nursing assistant ❍ C. Discuss the matter with the client's family ❍ D. Initiate a group session with the nursing assistant

Answer B is correct. The best action for the nurse to take is to explore the interaction with the nursing assistant. This will allow for clarification of the situation. Changing the assignment in answer A might need to be done, but talking to the nursing assistant is the first step. Answer C is incorrect because discussing the incident with the family is not necessary at this time; it might cause more problems. Answer C is not a first step, even though initiating a group session might be a plan for the future.

The nurse is assessing the client recently returned from surgery. The nurse is aware that the best way to assess pain is to: ❍ A. Take the blood pressure, pulse, and temperature ❍ B. Ask the client to rate his pain on a scale of 0-5 ❍ C. Watch the client's facial expression ❍ D. Ask the client if he is in pain

Answer B is correct. The best way to evaluate pain levels is to ask the client to rate his pain on a scale. In answer A, the blood pressure, pulse, and temperature can alter for other reasons than pain. Answers C and D are not as effective in determining pain levels.

A 4-year-old male is admitted to the unit with nephotic syndrome. He is extremely edematous. To decrease the discomfort associated with scrotal edema, the nurse should: ❍ A. Apply ice to the scrotum ❍ B. Elevate the scrotum on a small pillow ❍ C. Apply heat to the abdominal area ❍ D. Administer a diuretic

Answer B is correct. The child with nephotic syndrome will exhibit extreme edema. Elevating the scrotum on a small pillow will help with the edema. Applying ice is contraindicated; heat will increase the edema. Administering a diuretic might be ordered, but it will not directly help the scrotal edema. Therefore, answers A, C, and D are incorrect.

A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate? ❍ A. Blood pressure every 15 minutes ❍ B. Insertion of a Levine tube ❍ C. Cardiac monitoring ❍ D. Dressing changes two times per day

Answer B is correct. The client with pancreatitis frequently has nausea and vomiting. Lavage is often used to decompress the stomach and rest the bowel, so the insertion of a Levine tube should be anticipated. Answers A and C are incorrect because blood pressures are not required every 15 minutes, and cardiac monitoring might be needed, but this is individualized to the client. Answer D is incorrect because there are no dressings to change on this client.

A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170meq/L. What behavior changes would be most common for this client? ❍ A. Anger ❍ B. Mania ❍ C. Depression ❍ D. Psychosis

Answer B is correct. The client with serum sodium of 170meq/L has hypernatremia and might exhibit manic behavior. Answers A, C, and D are not associated with hypernatremia and are, therefore, incorrect.

The nurse is evaluating the client's pulmonary artery pressure. The nurse is aware that this test will evaluate: ❍ A. Pressure in the left ventricle ❍ B. The systolic, diastolic, and mean pressure of the pulmonary artery ❍ C. The pressure in the pulmonary veins ❍ D. The pressure in the right ventricle

Answer B is correct. The pulmonary artery pressure will measure the pressure during systole, diastole, and the mean pressure in the pulmonary artery. It will not measure the pressure in the left ventricle, the pressure in the pulmonary veins, or the pressure in the right ventricle. Therefore, answers A, C, and D are incorrect.

A 20-year-old is admitted to the rehabilitation unit following a motorcycle accident. Which would be the appropriate method for measuring the client for crutches? ❍ A. Measuring five finger breaths under the axilla ❍ B. Measuring 3 inches under the axilla ❍ C. Measuring the client with the elbows flexed 10° ❍ D. Measuring the client with the crutches 20 inches from the side of the foot

Answer B is correct. To correctly measure the client for crutches, the nurse should measure approximately 3 inches under the axilla. Answer A allows for too much distance under the arm. The elbows should be flexed approximately 35°, not 10°, as stated in answer C. The crutches should be approximately 6 inches from the side of the foot, not 20 inches, as stated in answer D.

The client is admitted with thrombophlebitis and an order for heparin. The medication should be administered using: ❍ A. Buretrol ❍ B. A tuberculin syringe ❍ C. Intravenous controller ❍ D. Three-way stop-cock

Answer B is correct. To safely administer heparin, the nurse should obtain an infusion controller. Too rapid infusion of heparin can result in hemorrhage. Answers A, C, and D are incorrect. It is not necessary to have a buretrol, an infusion filter, or a three-way stop-cock.

A client with osteomylitis has an order for a trough level to be done because he is taking Gentamycin. When should the nurse call the lab to obtain the trough level? ❍ A. Before the first dose ❍ B. 30 minutes before the fourth dose ❍ C. 30 minutes after the first dose ❍ D. 30 minutes after the fourth dose

Answer B is correct. Trough levels are the lowest blood levels and should be done 30 minutes before the third IV dose or 30 minutes before the fourth IM dose. Answers A, C, and D are incorrect.

A 25-year-old male is brought to the emergency room with a piece of metal in his eye. Which action by the nurse is correct? ❍ A. Use a magnet to remove the object. ❍ B. Rinse the eye thoroughly with saline. ❍ C. Cover both eyes with paper cups. ❍ D. Patch the affected eye only.

Answer C is correct. Covering both eyes prevents consensual movement of the affected eye. The nurse should not attempt to remove the object from the eye because this might cause trauma, as stated in answer A. Rinsing the eye, as stated in answer B, might be ordered by the doctor, but this is not the first step for the nurse. Answer D is not correct because often when one eye moves, the other also does.

The nurse is caring for a client with laryngeal cancer. Which finding ascertained in the health history would not be common for this diagnosis? ❍ A. Foul breath ❍ B. Dysphagia ❍ C. Diarrhea ❍ D. Chronic hiccups

Answer C is correct. Diarrhea is not common in clients with mouth and throat cancer. All the findings in answers A, B, and D are expected findings.

The nurse is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instruction should be given to the client? ❍ A. Rest in bed after taking the medication for at least 30 minutes ❍ B. Avoid rapid movements after taking the medication ❍ C. Take the medication with water only ❍ D. Allow at least 1 hour between taking the medicine and taking other medications

Answer C is correct. Fosamax should be taken with water only. The client should also remain upright for at least 30 minutes after taking the medication. Answers A, B, and D are not applicable to taking Fosamax and, thus, are incorrect.

The child with seizure disorder is being treated with Dilantin (phenytoin). Which of the following statements by the patient's mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy? ❍ A. "She is very irritable lately." ❍ B. "She sleeps quite a bit of the time." ❍ C. "Her gums look too big for her teeth." ❍ D. "She has gained about 10 pounds in the last 6 months."

Answer C is correct. Hyperplasia of the gums is associated with Dilantin therapy. Answer A is not related to the therapy; answer B is a side effect, and answer D is not related to the question.

The client with cirrhosis of the liver is receiving Lactulose. The nurse is aware that the rationale for the order for Lactulose is: ❍ A. To lower the blood glucose level ❍ B. To lower the uric acid level ❍ C. To lower the ammonia level ❍ D. To lower the creatinine level

Answer C is correct. Lactulose is administered to the client with cirrhosis to lower ammonia levels. Answers A, B, and D are incorrect because this does not have an effect on the other lab values.

The nurse is assessing the client admitted for possible oral cancer. The nurse identifies which of the following as a late-occurring symptom of oral cancer? ❍ A. Warmth ❍ B. Odor ❍ C. Pain ❍ D. Ulcer with flat edges

Answer C is correct. Pain is a late sign of oral cancer. Answers A, B, and D are incorrect because a feeling of warmth, odor, and a flat ulcer in the mouth are all early occurrences of oral cancer.

The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value might indicate a serious side effect of this drug? ❍ A. Uric acid of 5mg/dL ❍ B. Hematocrit of 33% ❍ C. WBC 2,000 per cubic millimeter ❍ D. Platelets 150,000 per cubic millimeter

Answer C is correct. Tegretol can suppress the bone marrow and decrease the white blood cell count; thus, a lab value of WBC 2,000 per cubic millimeter indicates side effects of the drug. Answers A and D are within normal limits, and answer B is a lower limit of normal; therefore answers A, B, and D are incorrect.

The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period? ❍ A. Assessment of the client's level of anxiety ❍ B. Evaluation of the client's exercise tolerance ❍ C. Identification of peripheral pulses ❍ D. Assessment of bowel sounds and activity

Answer C is correct. The assessment that is most crucial to the client is the identification of peripheral pulses because the aorta is clamped during surgery. This decreases blood circulation to the kidneys and lower extremities. The nurse must also assess for the return of circulation to the lower extremities. Answer A is of lesser concern, answer B is not advised at this time, and answer D is of lesser concern than answer A.

The client with an ileostomy is being discharged. Which teaching should be included in the plan of care? ❍ A. Use Karaya powder to seal the bag. ❍ B. Irrigate the ileostomy daily. ❍ C. Stomahesive is the best skin protector. ❍ D. Neosporin ointment can be used to protect the skin

Answer C is correct. The best protector for the client with an ileostomy to use is stomahesive. Answer A is not correct because the bag will not seal if the client uses Karaya powder. Answer B is incorrect because there is no need to irrigate an ileostomy. Neosporin, answer D, is not used to protect the skin because it is an antibiotic.

The client is admitted with chronic obstructive pulmonary disease. Blood gases reveal pH 7.36, CO2 45, O2 84, HCO3 28. The nurse would assess the client to be in: ❍ A. Uncompensated acidosis ❍ B. Compensated alkalosis ❍ C. Compensated respiratory acidosis ❍ D. Uncompensated metabolic acidosis

Answer C is correct. The client is experiencing compensated metabolic acidosis. The pH is within the normal range but is lower than 7.40, so it is on the acidic side. The CO2 level is elevated, the oxygen level is below normal, and the bicarb level is slightly elevated. In respiratory disorders, the pH will be the inverse of the CO2 and bicarb levels. This means that if the pH is low, the CO2 and bicarb levels will be elevated. Answers A, B, and D are incorrect because they do not fall into the range of symptoms.

The licensed practical nurse is observing a graduate nurse as she assesses the central venous pressure. Which observation would indicate that the graduate needs further teaching? ❍ A. The graduate places the client in a supine position to read the manometer. ❍ B. The graduate turns the stop-cock to the off position from the IV fluid to the client. ❍ C. The graduate instructs the client to perform the Valsalva maneuver during the CVP reading. ❍ D. The graduate notes the level at the top of the meniscus.

Answer C is correct. The client should breathe normally during a central venous pressure monitor reading. Answer A indicates understanding because the client should be placed supine if he can tolerate being in that position. Answers B and D indicate understanding because the stop-cock should be turned off to the IV fluid, and the reading should be done at the top of the meniscus.

The nurse is providing discharge teaching for a client taking dissulfiram (Antabuse). The nurse should instruct the client to avoid eating: ❍ A. Peanuts, dates, raisins ❍ B. Figs, chocolate, eggplant ❍ C. Pickles, salad with vinaigrette dressing, beef ❍ D. Milk, cottage cheese, ice cream

Answer C is correct. The client taking antabuse should not eat or drink anything containing alcohol or vinegar. The other foods in answers A, B, and D are allowed

The nurse is preparing a client with an axillo-popliteal bypass graft for discharge. The client should be taught to avoid: ❍ A. Using a recliner to rest ❍ B. Resting in supine position ❍ C. Sitting in a straight chair ❍ D. Sleeping in right Sim's position

Answer C is correct. The client with a femoral popliteal bypass graft should avoid activities that can occlude the femoral artery graft. Sitting in the straight chair and wearing tight clothes are prohibited for this reason. Resting in a supine position, resting in a recliner, or sleeping in right Sim's are allowed, as stated in answers A, B, and D.

A home health nurse is planning for her daily visits. Which client should the home health nurse visit first? ❍ A. A client with AIDS being treated with Foscarnet ❍ B. A client with a fractured femur in a long leg cast ❍ C. A client with laryngeal cancer with a laryngetomy ❍ D. A client with diabetic ulcers to the left foot

Answer C is correct. The client with laryngeal cancer has a potential airway alteration and should be seen first. The clients in answers A, B, and D are not in immediate danger and can be seen later in the day.

A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis? ❍ A. "Tell me about his pain." ❍ B. "What does his vomit look like?" ❍ C. "Describe his usual diet." ❍ D. "Have you noticed changes in his abdominal size?"

Answer C is correct. The least-helpful questions are those describing his usual diet. A, B, and D are useful in determining the extent of disease process and, thus, are incorrect.

Which of the following is the best indicator of the diagnosis of HIV? ❍ A. White blood cell count ❍ B. ELISA ❍ C. Western Blot ❍ D. Complete blood count

Answer C is correct. The most definitive diagnostic tool for HIV is the Western Blot. The white blood cell count, as stated in answer A, is not the best indicator, but a white blood cell count of less than 3,500 requires investigation. The ELISA test, answer B, is a screening exam. Answer D is not specific enough.

The nurse is caring for the client following a cerebral vascular accident. Which portion of the brain is responsible for taste, smell, and hearing? ❍ A. Occipital ❍ B. Frontal ❍ C. Temporal ❍ D. Parietal

Answer C is correct. The temporal lobe is responsible for taste, smell, and hearing. The occipital lobe is responsible for vision. The frontal lobe is responsible for judgment, foresight, and behavior. The parietal lobe is responsible for ideation, sensory functions, and language. Therefore, answers A, B, and D are incorrect.

Which assignment should not be performed by the licensed practical nurse? ❍ A. Inserting a Foley catheter ❍ B. Discontinuing a nasogastric tube ❍ C. Obtaining a sputum specimen ❍ D. Initiating a blood transfusion

Answer D is correct. A licensed practical nurse should not be assigned to initiate a blood transfusion. The LPN can assist with the transfusion and check ID numbers for the RN. The licensed practical nurse can be assigned to insert Foley and French urinary catheters, discontinue Levine and Gavage gastric tubes, and obtain all types of specimens, so answers A, B, and C are incorrect.

Which of the following post-operative diets is most appropriate for the client who has had a hemorroidectomy? ❍ A. High-fiber ❍ B. Low-residue ❍ C. Bland ❍ D. Clear-liquid

Answer D is correct. After surgery, the client will be placed on a clear-liquid diet and progressed to a regular diet. Stool softeners will be included in the plan of care, to avoid constipation. Later, a high-fiber diet, in answer A, is encouraged, but this is not the first diet after surgery. Answers B and C are not diets for this type of surgery.

A client with acute leukemia develops a low white blood cell count. In addition to the institution of isolation, the nurse should: ❍ A. Request that foods be served with disposable utensils ❍ B. Ask the client to wear a mask when visitors are present ❍ C. Prep IV sites with mild soap and water and alcohol ❍ D. Provide foods in sealed single-serving packages

Answer D is correct. Because the client is immune-suppressed, foods should be served in sealed containers, to avoid food contaminants. Answer B is incorrect because of possible infection from visitors. Answer A is not necessary, but the utensils should be cleaned thoroughly and rinsed in hot water. Answer C might be a good idea, but alcohol can be drying and can cause the skin to break down.

A client has been receiving cyanocobalamine (B12) injections for the past 6 weeks. Which laboratory finding indicates that the medication is having the desired effect? ❍ A. Neutrophil count of 60% ❍ B. Basophil count of 0.5% ❍ C. Monocyte count of 2% ❍ D. Reticulocyte count of 1%

Answer D is correct. Cyanocolamine is a B12 medication that is used for pernicious anemia, and a reticulocyte count of 1% indicates that it is having the desired effect. Answers A, B, and C are white blood cells and have nothing to do with this medication.

The client is diagnosed with multiple myoloma. The doctor has ordered cyclophosphamide (Cytoxan). Which instruction should be given to the client? ❍ A. "Walk about a mile a day to prevent calcium loss." ❍ B. "Increase the fiber in your diet." ❍ C. "Report nausea to the doctor immediately." ❍ D. "Drink at least eight large glasses of water a day."

Answer D is correct. Cytoxan can cause hemorrhagic cystitis, so the client should drink at least eight glasses of water a day. Answers A and B are not necessary and, so, are incorrect. Nausea often occurs with chemotherapy, so answer C is incorrect.

The client is admitted to the emergency room with shortness of breath, anxiety, and tachycardia. His ECG reveals atrial fibrillation with a ventricular response rate of 130 beats per minute. The doctor orders quinidine sulfate. While he is receiving quinidine, the nurse should monitor his ECG for: ❍ A. Peaked P wave ❍ B. Elevated ST segment ❍ C. Inverted T wave ❍ D. Prolonged QT interval

Answer D is correct. Quinidine can cause widened Q-T intervals and heart block. Other signs of myocardial toxicity are notched P waves and widened QRS complexes. The most common side effects are diarrhea, nausea, and vomiting. The client might experience tinnitus, vertigo, headache, visual disturbances, and confusion. Answers A, B, and C are not related to the use of quinidine.

A client is admitted with a Ewing's sarcoma. Which symptoms would be expected due to this tumor's location? ❍ A. Hemiplegia ❍ B. Aphasia ❍ C. Nausea ❍ D. Bone pain

Answer D is correct. Sarcoma is a type of bone cancer; therefore, bone pain would be expected. Answers A, B, and C are not specific to this type of cancer and are incorrect.

A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period? ❍ A. Teaching how to irrigate the illeostomy ❍ B. Stopping electrolyte loss in the incisional area ❍ C. Encouraging a high-fiber diet ❍ D. Facilitating perineal wound drainage

Answer D is correct. The client with a perineal resection will have a perineal incision. Drains will be used to facilitate wound drainage. This will help prevent infection of the surgical site. The client will not have an illeostomy, as in answer A; he will have some electrolyte loss, but treatment is not focused on preventing the loss, so answer B is incorrect. A high-fiber diet, in answer C, is not ordered at this time.

The licensed practical nurse is working with a registered nurse and a patient care assistant. Which of the following clients should be cared for by the registered nurse? ❍ A. A client 2 days post-appendectomy ❍ B. A client 1 week post-thyroidectomy ❍ C. A client 3 days post-splenectomy ❍ D. A client 2 days post-thoracotomy

Answer D is correct. The most critical client should be assigned to the registered nurse; in this case, that is the client 2 days post-thoracotomy. The clients in answers A and B are ready for discharge, and the client in answer C who had a splenectomy 3 days ago is stable enough to be assigned to an LPN.

Which of the following roommates would be best for the client newly admitted with gastric resection? ❍ A. A client with Crohn's disease ❍ B. A client with pneumonia ❍ C. A client with gastritis ❍ D. A client with phlebitis

Answer D is correct. The most suitable roommate for the client with gastric resection is the client with phlebitis because phlebitis is an inflammation of the blood vessel and is not infectious. Crohn's disease clients, in answer A, have frequent stools that might spread infections to the surgical client. The client in answer B with pneumonia is coughing and will disturb the gastric client. The client with gastritis, in answer C, is vomiting and has diarrhea, which also will disturb the gastric client.

The charge nurse is making assignments for the day. After accepting the assignment to a client with leukemia, the nurse tells the charge nurse that her child has chickenpox. Which action should the charge nurse take? ❍ A. Change the nurse's assignment to another client ❍ B. Explain to the nurse that there is no risk to the client ❍ C. Ask the nurse if the chickenpox have scabbed ❍ D. Ask the nurse if she has ever had the chickenpox

Answer D is correct. The nurse who has had the chickenpox has immunity to the illness. Answer A is incorrect because more information is needed to determine whether a change in assignment is necessary. Answer B is incorrect because there could be a risk to the immune-suppressed client. Answer C is incorrect because the client who is immune-suppressed could still be at risk from the nurse's exposure to the chickenpox, even if scabs are present.

The doctor has ordered 80mg of furosemide (Lasix) two times per day. The nurse notes the patient's potassium level to be 2.5meq/L. The nurse should: ❍ A. Administer the Lasix as ordered ❍ B. Administer half the dose ❍ C. Offer the patient a potassium-rich food ❍ D. Withhold the drug and call the doctor

Answer D is correct. The potassium level of 2.5meq/L is extremely low. The normal is 3.5-5.5meq/L. Lasix (furosemide) is a nonpotassium sparing diuretic, so answer A is incorrect. The nurse cannot alter the doctor's order, as stated in answer B, and answer C will not help with this situation.

The home health nurse is planning for the day's visits. Which client should be seen first? ❍ A. The 78-year-old who had a gastrectomy 3 weeks ago with a PEG tube ❍ B. The 5-month-old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension ❍ C. The 50-year-old with MRSA being treated with Vancomycin via a PICC line ❍ D. The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter

Answer D is correct. The priority client is the one with multiple sclerosis who is being treated with cortisone via the central line. This client is at highest risk for complications. MRSA, in answer C, is methicillin-resistant staphylococcus aureas. Vancomycin is the drug of choice and can be administered later, but its use must be scheduled at specific times of the day to maintain a therapeutic level. Answers A and B are incorrect because these clients are more stable.

The nurse is assisting in the care of a patient who is 2 days postoperative from a hemorroidectomy. The nurse would be correct in instructing the patient to: ❍ A. Avoid a high-fiber diet because this can hasten the healing time ❍ B. Continue to use ice packs until discharge and then when at home ❍ C. Take 200mg of Colace bid to prevent constipation ❍ D. Use a sitz bath after each bowel movement to promote cleanliness and comfort

Answer D is correct. The use of a sitz bath will help with the pain and swelling associated with a hemorroidectomy. The client should eat foods high in fiber, so answer A is incorrect. Ice packs, as stated in answer B, are ordered immediately after surgery only. Answer C, a stool softener, can be ordered, but only by the doctor.

A client with cancer develops xerostomia. The nurse can help alleviate the discomfort associated with xerostomia by: ❍ A. Offering hard candy ❍ B. Administering analgesic medications ❍ C. Splinting swollen joints ❍ D. Providing saliva substitute

Answer D is correct. Xerostomia is dry mouth, and offering the client a saliva substitute will help the most. Eating hard candy in answer A can further irritate the mucosa and cut the tongue and lips. Administering an analgesic might not be necessary; thus, answer B is incorrect. Splinting swollen joints, in answer C, is not associated with xerostomia.