1.

A nurse is preparing to care for a client with a potassium a complete blood count, coagulation studies, and
deficit. The nurse reviews the client's record and electrolytes and creatinine levels. Which of the following
determines that the client was at risk for developing the results should be reported to the surgeon's office by the
nurse, knowing that it could cause surgery to be
potassium deficit because the client:
postponed?
a. has renal failure a. sodium, 141 mEq/L
b. requires nasogastric suction b. hemoglobin, 8.0 g/dL
c. has a history of Addison's disease c. platelets, 210,000 mm3
d. is taking a potassium-sparing diuretic d. serum creatinine, 0.8 mg/dL

2. A client with a history of abusing barbiturates abruptly 8. A client with gastroesophagel reflux disease (GERD) has
received extensive client teaching about the disease and
stops taking the medication. The nurse should give priority
related home care. Which statement by the client suggests
to assessing the client for: that the client is implementing the teaching?
a. Depression and suicidal ideation a. “I usually drink a small glass of water before
b. Tachycardia and diarrhea bed.”
c. Muscle cramping and abdominal pain b. “I avoid food such as celery and bran cereal.”
d. Tachycardia and euphoric mood c. “I changed from butter to margarine.”
d. “I quit drinking coffee and cola drinks.”
3. A nurse reviews the blood gas results of client with
9. Which complication of cardiac catheterization should the
Guillain-Barre syndrome. The nurse analyzes the results nurse monitor for in the initial 24 hours after the
and determines that the client is experiencing respiratory procedure?
acidosis. Which of the following validates the nurse's a. angina at rest
findings? b. thrombus formation
a. pH 7.25, Pco2 50 mm Hg c. dizziness
d. falling blood pressure
b. pH 7.35, Pco2 40 mm Hg
c. pH 7.50, Pco2 52 mm Hg 10. During hospital rounds, a nursing supervisor smells smoke
d. pH 7.52, Pco2 28 mm Hg coming from a client’s bathroom. She opens the bathroom
door and finds the client unresponsive on the floor and the
4. During the assessment of a laboring client, the nurse notes waste can on fire. Which is her most appropriate
that the FHT are loudest in the upper-right quadrant. The response?
infant is most likely in which position? a. Drag the client from the bathroom and close the
door.
a. Right breech presentation
b. Activate the fire alarm located outside the
b. Right occipital anterior presentation client’s room.
c. Left sacral anterior presentation c. Move the waste can to the shower and turn the
d. Left occipital transverse presentation shower on.
d. Call for help from other staff members.
5. A client is hypovolemic and plasma expanders are not
available. The nurse anticipates that which of the following 11. The nurse is speaking at a community meeting about
solutions available on the nursing unit will be prescribed personal responsibility for health promotion. A participant
by the physician? asks about chiropractic treatment for illnesses. What
a. 5% dextrose in water should be the focus of the nurse’s response?
b. 0.9% sodium chloride a. Electrical energy fields
c. 0.45% sodium chloride b. Spinal column manipulation
d. 5% dextrose in 0.45% sodium chloride c. Mind-body balance
d. Exercise of joints
6. A 68-year-old woman is diagnosed with thrombocytopenia
due to acute lymphocytic leukemia. She is admitted to the 12. A client with Parkinsonism is having problems with
hospital for treatment. The nurse should assign the ambulation and is experiencing wavering and stumbling.
patient: Which client teaching would be most beneficial in
a. to a private room so she will not infect other preventing the client from falling?
patients and health care workers. a. Keep the arms as still as possible when walking.
b. to a private room so she will not be infected by b. Walk with the feet spaced at hip width.
other patients and health care workers. c. Maintain a slightly forward-leaning position.
c. to a semiprivate room so she will have d. Focus eyes on the level of the horizon.
stimulation during her hospitalization.
d. to a semiprivate room so she will have the 13. A nurse enters a client’s room to discover that the client
opportunity to express her feelings about her has no pulse or respirations. After calling for help, the first
illness. action the nurse should take is
a. Start a peripheral IV
7. A client who has undergone preadmission testing has had b. Initiate closed-chest massage
blood drawn for serum laboratory studies, including c. Establish an airway
 d. Obtain the crash cart c. After taking the medication, he adds water to
the container and drinks that too
14. A client thrombocyte count is 510,000. Which nursing d. He uses a plastic or Styrofoam cup to mix the
intervention is important?
medication solution
a. Observe for nosebleeds
b. Use a manual sphygmomanometer
21. The nurse hears an attending physician asking an intern to
c. Encourage fluid intake
prescribe a hypotonic intravenous (IV) solution for a client.
d. Minimize physical activity
Which of the following IV solutions would the nurse
expect the intern to prescribe?
15. A parent asks the school nurse how to eliminate lice from
a. 5% dextrose in water
their child. What is the most appropriate response by the
b. 10% dextrose in water
nurse?
c. 0.45% sodium chloride
a. Cut the child’s hair short to remove the nits
d. 5% dextrose in 0.9% sodium chloride
b. Apply warm soaks to the head twice daily
c. Wash the child’s linen and clothing in a bleach
22. A 25-year-old client with a recent history of sinusitis
solution
demonstrates a positive Brudzinski sign. The therapeutic
d. Apply pediculicides
approach by the nurse that has the highest priority is:
a. Controlling intracranial pressure
16. Which assessment of the lungs by auscultation would the
b. Administering prescribed antibiotics
nurse expect to evaluate if a client has a left lower lobe
c. Adding pads to the side rails of the bed
consolidation?
d. Hydrating the patient with 0.45% Saline
a. Absent breath sounds
b. Bronchophony
23. A nurse has just reassessed the condition of a
c. Vesicular breath sounds
postoperative client who was admitted 1 hour ago to the
d. Wheezes
surgical unit. The nurse plans to monitor which of the
following parameters most carefully during the next hour?
17. A nurse reviews a client's electrolyte laboratory report and
a. urinary output of 20 ml/hr
notes that the potassium level is 3.2 mEq/L. Which of the b. temperature of 37.6 C (99.6F)
following would the nurse note on the electrocardiogram c. blood pressure of 100/70 mmHg
as a result of the laboratory value? d. serous drainage on the surgical dressing
a. U waves
b. absent P waves 24. The nurse observes that a fire has started in the client’s
c. elevated T waves room. Which action should the nurse take first?
a. Confine the fire to the client’s room
d. elevated ST segment
b. Extinguish the fire
c. Pull the fire alarm
18. Which plan would be most appropriate for a 34-week d. Rescue the client
pregnant woman who is being treated with magnesium
sulphate and bed rest for pregnancy induced 25. A client is admitted to the emergency room with renal
hypertension? calculi and is complaining of moderate to severe flank pain
a. Assessing the equality of pedal pulse and nausea. The client’s temperature is 100.8 degrees
b. Assessing the abdominal circumference Fahrenheit. The priority nursing goal for this client is
c. Assessing for an increase in urine output a. Maintain fluid and electrolyte balance
d. Obtaining the client’s daily weight b. Control nausea
c. Manage pain
19. A nurse reviews the arterial blood gas results of client and d. Prevent urinary tract infection
notes the following: pH 7.45, Pco2 of 30 mm Hg, and HCO3
of 22 mEq/L. The nurse analyzes these results as indicating 26. Which assignment would be appropriate for the labor and
which condition? delivery (L&D) nurse who will be working for one shift on
a. metabolic acidosis, compensated the Medical Surgical Unit?
b. respiratory alkalosis, compensated a. A 3-year-old with croup
b. A 30-year-old with malignant hypertension
c. metabolic acidosis, uncompensated
c. A 40-year-old with unstable angina
d. respiratory alkalosis, uncompensated d. A 50-year-old with congestive heart failure

20. A client with inflammatory bowel disease is placed on a 27. The nurse is performing a neurological assessment on a
daily dose of cyclosporine (Sandimmune) in an oral client post right CVA. Which finding, if observed by the
solution form. Which behaviour by the client demonstrates nurse, would warrant immediate attention?
knowledge of how to take the drug? a. Decrease in level of consciousness
b. Loss of bladder control
a. He mixes it in a citrus juice and stirs it well
c. Altered sensation to stimuli
b. He waits at least 30 minutes to take the drug d. Emotional ability
after mixing it in a solution
28. After establishing IV access, what would be the best for c. Growing pain radiating to the lower back
the nurse to document immediately after procedure? d. Pain on light palpitation in epigastric area with
a. The type of catheter used and number of diarrhea
venepuncture attempts
b. The type of IV fluid hung and equipment used
c. The date, time, venipuncture site, type and 35. A client is receiving a continuous intravenous infusion of
gauge of catheter, and IV fluid hung heparin sodium to treat deep vein thrombosis. The
d. Type amount and flow rate of IV fluid, condition client's activated partial thromboplastin time (aPTT) time is
of IV site 65 seconds. The client's baseline before the initiation of
therapy was 30 seconds. The nurse anticipates that which
29. A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The action is needed?
health care provider has written a new order to give
a. discontinuing the heparin infusion
metoprolol (Lopressor) 25 mg. B.I.D. In assessing the client
prior to administering the medications, which of the b. increasing the rate of the heparin infusion
following should the nurse report immediately to the c. decreasing the rate of heparin infusion
health care provider? d. leaving the rate of the heparin infusion at is
a. Blood pressure 94/60
b. Heart rate 76 36. What is the priority of care after the urinary catheter is
c. Urine output 50 ml/hour removed?
d. Respiratory rate 16
a. Encourage client to eliminate fluid intake
30. Which statement made by the new mother indicates an b. Document size of catheter and client’s tolerance
understanding of screening for PKU for her newborn son of procedure
who she is breastfeeding? c. Evaluate client for normal voiding
a. “I will have him tested 24 hours after birth.” d. Documentation of client teaching
b. “I will return to the clinic in 48 hours for the
screening.” 37. A client receiving a transfusion of packed red blood
c. “I will return in 1 week to obtain blood samples.” cells (PRBCs) begins to vomit. The nurse takes the
d. “I will return in 1 month for the screening.” client's blood pressure and it is 90/50 mm Hg, from a
baseline of 125/78 mm Hg. The client's temperature is
31. Discharge instructions for a client taking alprazolam 100.8F orally, from a baseline of 99.2F orally. The nurse
(Xanax) should include which of the following? determines that the client may be experiencing which
a. Sedative hypnotics are effective analgesics complication of a blood transfusion?
b. Sudden cessation of alprazolam (Xanax) can a. Septicaemia
cause rebound insomnia and nightmares b. Hyperkalemia
c. Caffeine beverages can increase the effect of c. Circulatory overload
sedative hypnotics d. Delayed transfusion reaction
d. Avoidance of excessive exercise and high
temperatures is recommended 38. Which clinical findings indicate a complication from
diabetes insipidus?
32. Which of these schedules would be most appropriate to a. Urine specific gravity 1.001
recommend to a pre-menopausal woman regarding her b. Serum sodium 135
self-breast exam? c. Urine output greater than 200cc/hr
a. One week prior to monthly period d. Weight loss of 2 lbs
b. One week after the menstrual period
c. During every shower 39. A physician prescribes home health nurse visits for a child
d. The same day monthly discharged with Reye's syndrome. During a home visit, a
nurse instructs the parents about the residual effects of
33. A nurse caring for a group of clients reviews the Reye's syndrome. Which statement, if made by the
electrolyte laboratory results and notes a potassium level parents, indicates a need for further instruction?
of 5.5 mEq/L on one client's laboratory report. The nurse a. we need to check for jaundiced skin and eyes
understands that which client is at highest risk for the everyday
development of a potassium value at this level? b. we need to have the child nap during the day to
provide rest
a. the client with colitis
c. we need to decrease the stimuli at home to
b. the client with Cushing's syndrome prevent increased intracranial pressure
c. the client who has been overusing laxatives d. we need to give frequent, small, nutritious meals
d. the client who has sustained a traumatic burn to decrease the amount of vomiting
34. The nurse is assessing a child with a tentative diagnosis of
appendicitis. This diagnosis is most often manifested by: 40. Which nursing actions is most appropriate for a client
receiving a tube feeding around the clock?
a. Sharp pain with extreme gastric distention
a. Rinse the bag and change the formula every 4
b. Rebound tenderness in the right lower hours
abdominal quadrant, with decreased bowel b. Rinse the bag and change the formula every shift
sounds c. Change the bag and formula every shift
 d. Rinse the bag and change the formula every 2 48. Following hip replacement surgery, an elderly client is
hours ordered to begin ambulation with a walker. Which of the
following statements by the nurse is best?
41. What would the nurse expect to see while assessing the
a. “Sit in a low chair for ease in getting up to use
growth of children during their school age years?
a. Decreasing amounts of body fat and muscle the walker.”
mass b. “Make sure rubber caps are in place on all four
b. Little change in body appearance from year to legs of the walker.”
year c. “You will begin weight-bearing on the affected
c. Progressive height increase of 4 inches each year hip soon.”
d. Yearly weight gain of about 5.5 pounds per year d. “Practice tying your own shoes before you begin
ambulation.”
42. An adult comes to the clinic with complaints of frequency
and burning on urination. The nurse expects that what test
will be ordered for the client? 49. A nurse reviews the electrolyte results of an assigned
a. Clean catch urine for culture and sensitivity client and notes that the potassium level is 5.4 mEq/L.
b. CBC and electrolytes Which of the following would the nurse expect to note on
c. Cystoscopy the electrocardiogram as a result of the laboratory value?
d. Strain of all urine for calculi a. ST depression
b. inverted T wave
43. A child who has recently been diagnosed with cystic
fibrosis is in a pediatric clinic where a nurse is performing c. prominent U wave
an assessment. Which later finding of this disease would d. tall peaked T waves
the nurse not expect to see at this time?
a. Positive sweat test 50. A 22-year-old woman comes to the hospital at term in the
b. Bulky greasy stools early stages of labor. A diagnosis of complete placenta
c. Moist, productive cough
previa is made. It would be MOST important for the nurse
d. Meconium ileus
to take which of the following actions?
44. The nurse is inserting an indwelling urinary catheter in an a. Start an IV of terbutaline (Brethine) and monitor
adult woman. The nurse locates landmarks before the patient’s vital signs closely.
inserting the catheter. The urethral opening is located: b. Prepare the patient for an immediate cesarean
a. Above the clitoris section.
b. Behind the vagina c. Maintain the patient on bedrest until
c. Between the clitoris and vagina
spontaneous vaginal delivery is achieved.
d. Between the vagina and rectum
d. Monitor the patient’s length and duration of
45. While assessing a 1 month-old infant, which finding should contractions.
the nurse report immediately?
a. Abdominal respirations 51. An adult female client has a hemoglobin level of 10.8 g/dL.
b. Irregular breathing rate The nurse interprets that this result is most likely caused
c. Inspiratory grunt by which of the following conditions noted in the client's
d. Increased heart rate with crying history?
a. Dehydration
46. The nurse returns to the nurse’s station after making client b. heart failure
rounds and finds four phone messages. Which of the c. iron deficiency anemia
following messages should the nurse return first? d. chronic obstructive pulmonary disease
a. A client with hepatitis A who states, “My arms
and legs are itching.” 52. Which of the following nursing observations would
b. A client with a cast on the right leg who states, “I indicate to the nurse that a child with epiglottitis is having
have a funny feeling in my right leg.” an early complication of hypoxemia?
c. A client with osteomyelitis of the spine who a. Heart rate of 148 beats per minute.
states, “I am so nauseous that I can’t eat.” b. Bluish discoloration of the skin.
d. A client with arthritis who states, “I am having c. Bluish discoloration around the mouth.
trouble sleeping at night.” d. Difficulty swallowing.

47. A client is recovering from a hip replacement and is taking 53. The nurse is told by a physician that a client in
Tylenol #3 every 3 hours for pain. In checking the client, hypovolemic shock will require plasma expansion. The
which finding suggests a side effect of the analgesic? nurse anticipates receiving an order to transfuse which
a. Bruising at the operative site product?
b. Elevated heart a. Albumin
c. Decreased platelet count b. Platelets
d. No bowel movement for 3 days c. Cryoprecipitate
d. Packed red blood cells
54. The neonatal nurse is instructing the family of a newborn d. Instruct the client’s wife to call the doctor if his
about an apnea monitor. The nurse should be MOST symptoms become worse
concerned if a family member makes which of the
following statements? 60. Which of the following nursing actions is MOST important
a. “We will be able to leave our baby for brief to provide a patient with effective pain relief?
periods of time.” a. Teach the patient about his pain.
b. “We plan to sleep by our baby’s crib.” b. Establish a trusting relationship with the patient.
c. “We can remove the monitor during our baby’s c. Determine how various relaxation techniques
bath.” affect the pain.
d. “A family member will closely watch the monitor d. Provide alternative measures to relieve pain.
all the time.
61. The nurse practicing in a maternity setting recognizes that
55. A nurse is reviewing the laboratory results for a child the post mature fetus is at risk due to
scheduled for tonsillectomy. The nurse determines that a. Excessive fetal weight
which laboratory value is most significant to review? b. Low blood sugar levels
a. Creatinine c. Depletion of subcutaneous fat
b. Prothrombin d. Progressive placental insufficiency
c. Sedimentation rate
d. Blood urea nitrogen level 62. An adult woman is admitted to an acute locked psychiatric
unit one month prior to an election. She requests the
56. A 20-year-old client has a cast applied for a fracture of the opportunity to vote in the upcoming election. Which of the
right femur. Three hours later, the client complains that it following responses by the nurse is BEST?
is hot and painful under his cast. Which of the following is a. “You are not eligible to vote because you are a
the MOST appropriate action for the nurse to take? psychiatric patient.”
a. Assess the cast for wet spots and increase air b. “I’ll make the appropriate arrangements for you
circulation in the room. to vote.”
b. Check the circulation in his casted extremity and c. “You may vote only if you are discharged by
change the client’s position. Election Day.”
c. Take the client’s temperature and observe him d. “I’ll contact the Election Board to see if you are
for other signs of infection. registered to vote.”
d. Medicate the client for pain and notify the
physician of his complaint. 63. The nurse is caring for a client with clinical depression who
is receiving a MAO inhibitor. When providing instructions
57. At a community health fair the blood pressure of a 62 about precautions with this medication, which action
year-old client is 160/96. The client states “My blood should the nurse stress to the client as important?
pressure is usually much lower.” The nurse should tell the a. Avoid cheese and chocolate
client to b. Take frequent naps
a. go get a blood pressure check within the next 48 c. Take the medication with milk
to 72 hours d. Avoid walking without assistance
b. check blood pressure again in 2 months
c. see the health care provider immediately 64. A client is scheduled for a traditional abdominal
d. visit the health care provider within 1 week for a cholecystectomy. Which of the following statements, if
BP check made by the nurse to the client the night before surgery, is
MOST important?
58. Which of the following plans would be MOST appropriate a. “It is important for you to eat foods from every
for the nurse to use to prepare a 10-year-old for a cardiac level of the food pyramid and avoid excessive
catheterization? fats in your diet.”
a. Show a videotape specifically prepared for b. “Place the pillow against your abdomen, take
children about cardiac catheterization. three deep breaths, hold your breath, and then
b. Provide the child with a pamphlet about the cough two or three times.”
procedure and encourage him to read it. c. “There will be a machine available to you after
c. Draw a picture of a heart and explain where the surgery for you to use to continuously receive
tube will go and what the doctor will see. pain medication.”
d. Present a puppet show explaining the anatomy d. “You may come back from surgery with a tube in
and physiology of the heart. your nose that drains your gall bladder.”

59. The home health nurse visits a male client to provide 65. A nurse caring for a group of clients reviews the
wound care and finds the client lethargic and confused. His electrolyte laboratory results and notes a sodium level of
wife states he fell down the stairs 2 hours ago. The nurse 130 mEq/L on one client's laboratory report. The nurse
should
understands that which client is at highest risk for the
a. Place a call to the client’s health care provider
for instructions development of sodium value at this level?
b. Send him to the emergency room for evaluation a. the client with renal failure
c. Reassure the client’s wife that the symptoms are b. the client who is taking diuretics
transient c. the client with hyperaldosteronism
 d. the client who is taking corticosteroids a. difficulty in swallowing
b. bleeding during surgery
66. A 22-year-old mother of a 4-year-old boy comes to the c. exudate in the throat area
d. presence of loose teeth
antepartal clinic. Her second pregnancy has just been
confirmed. During this initial visit, it MOST important for 72. A mother brings her 17-month-old son to the well-baby
the nurse to clinic for a routine check-up. She confides to the nurse that
a. assess the client’s feelings about pregnancy, she is concerned because her son sucks his thumb,
labor, and delivery. especially at night when he is put to bed. Which of the
b. obtain a history of the client’s last labor and suggestions by the nurse would be BEST?
delivery. a. “If you want the behavior to stop put a negative
reinforcer, such as red pepper, on this thumb.”
c. determine how the client’s 4-year-old feels
b. “Don't intervene at this time. This behavior
about the pregnancy. usually subsides after 24 months of age.”
d. identify the client’s general health needs. c. “What you are seeing is a common form of self-
stimulation. You should discourage this
67. The nurse is teaching a client who has iron deficiency behavior.”
anemia about foods she should include in her diet. The d. “This behavior will cause malformation of his
nurse determines that the client understands the dietary teeth. You should wrap his thumb at bedtime.”
modifications if she selects which of the following from her
73. The hospital has sounded the call for a disaster drill on the
menu? evening shift. Which of these clients would the nurse put
a. nuts and milk first on the list to be discharged in order to make a room
b. coffee and tea available for a new admission?
c. cooked rolled oats and fish a. A middle aged client with a history of being
d. oranges and dark leafy vegetables ventilator dependent for over 7 years and
admitted with bacterial pneumonia five days ago
68. The nurse is caring for a client with a perforated bowel b. A young adult with diabetes mellitus Type 2 for
secondary to a bowel obstruction. At the time the over 10 years and admitted with antibiotic
diagnosis is made, which of the following should be a induced diarrhea 24 hours ago
priority in the nursing care plan? c. An elderly client with a history of hypertension,
a. Maintain the client in a supine position. hypercholesterolemia and lupus, and was
b. Notify the client’s next-of-kin. admitted with Stevens-Johnson syndrome that
c. Prepare the client for emergency surgery. morning
d. Remove the nasogastric tube. d. An adolescent with a positive HIV test and
admitted for acute cellulitus of the lower leg 48
69. A physician tells a client that the client needs a blood hours ago
transfusion and that the blood sample must be drawn first
for blood typing and crossmatching. After the physician 74. The nurse is caring for clients in the outpatient clinic. A
leaves, the client asks the nurse, "What exactly isblood young adult female is seeking help for weight loss. Her
type, anyway?" The nurse responds with which of the weight is 257 pounds, and she is 5′7″ tall. Which of the
following statements? following indicates the most appropriate diet choices for
a. the blood type represents an antigen found on breakfast?
the surface of the red blood cells a. Applesauce, cream of wheat, toast.
b. the blood type represents an antibody found on b. Scrambled eggs and toast, one slice of bacon.
the surface of the red blood cells c. One glass of grapefruit juice.
c. the blood type represents an antibody that d. Bagel with two ounces of cream cheese and a
normally circulates in the blood plasma banana.
d. the blood type represents an antigen that
normally circulates in the blood plasma 75. Which of the following should the nurse implement to
prepare a client for a KUB (Kidney, Ureter, Bladder)
70. The doctor writes an order for piperacillin (Pipracil) 3 g IV radiograph test?
q6h for an adult client. Before administering this drug, the a. Client must be NPO before the examination
nurse should: b. Enema to be administered prior to the
a. check for known allergies to medications. examination
b. ensure that the client’s respiratory rate is over c. Medicate client with Lasix 20 mg IV 30 minutes
12. prior to the examination
c. administer dexamethasone sodium phosphate d. No special orders are necessary for this
(Decadron) 2 mg IV stat. examination
d. check the client’s blood pressure both sitting and
standing 76. A toddler admitted with an elevated blood lead level is to
be treated with intramuscular (IM) injections of calcium
71. A child is scheduled for a tonsillectomy. A nurse plans care, disodium edetate (Calcium EDTA) and dimercaprol (BAL).
knowing that which of the following would present the Which of the following nursing actions should have the
highest risk of aspiration during surgery? highest priority?
 a. Keep a tongue blade at the bedside. 82. A client who is receiving hydralazine (Apresoline) q6h has a
b. Encourage the child to participate in play blood pressure of 90/60. Which of the following nursing
therapy. actions would be MOST appropriate?
c. Apply cool soaks to the injection site.
a. Withhold the medication.
d. Rotate the injection sites.
b. Check the urinary output.
77. The nurse is caring for a client who had a total hip c. Administer the medication.
replacement 4 days ago. Which assessment requires the d. Increase the potassium intake.
nurse’s immediate attention?
a. I have bad muscle spasms in my lower leg of the 83. A client is being weaned from parenteral nutrition (PN)
affected extremity. and is expected to begin taking solid food today. The
b. “I just can’t ‘catch my breath’ over the past few ongoing solution rate has been 100 ml/hr. A nurse
minutes and I think I am in grave danger.” anticipates that which of the following orders regarding
c. “I have to use the bedpan to pass my water at the PN solution will accompany the diet order?
least every 1 to 2 hours.” a. discontinue the PN
d. “It seems that the pain medication is not working b. decrease PN rate to 50 ml/hr
as well today.” c. hang 1000 ml 0.9% normal saline
d. continue current infusion rate orders for PN
78. The nurse is instructing a client being discharged on
tranylcypromine sulfate (Parnate). The nurse knows 84. A 34-year-old multipara comes to the prenatal clinic during
further instruction is needed if the client makes which of her fifth month of pregnancy. The client complains to the
the following statements? nurse that her breasts are sensitive and sore. Which of the
a. “To celebrate, my wife and I are going out for following suggestions by the nurse is BEST?
pepperoni pizza and wine tonight.” a. Apply warm compresses to your breasts and take
b. “I plan to use sunblock at the beach this two aspirin as needed.
summer.” b. Massage your breasts with lotion and wear
c. “When I get home, I am going to start a diet so I loose-fitting clothing.
can lose some weight.” c. Apply cold compresses to your breasts and wear
d. “Now that I feel so much better, I have more a well-fitting, supportive bra.
energy” d. Take a diuretic once a day and avoid touching
your breasts.
79. An antibiotic IM injection for a 2 year-old child is ordered.
The total volume of the injection equals 2.0 ml The correct 85. The nurse enters a client's room to assess the client, who
action is to: began receiving a blood transfusion 45 minutes earlier,
a. Administer the medication in 2 separate and notes that the client is flushed and dyspneic. On
injections assessment, the nurse auscultates the presence of crackles
b. Give the medication in the dorsal gluteal site in the lung bases. The nurse determines that his client
c. Call to get a smaller volume ordered most likely is experiencing which complication of blood
d. Check with pharmacy for a liquid form of the transfusion therapy?
medication a. Bacteremia
b. Hypovolemia
80. A college student was in a motor vehicle accident six c. Fluid overload
months ago. Although he was minimally injured, his friend d. Transfusion reaction
was killed. The client comes to Student Health Services
with the complaints of not being able to study, not 86. The nurse is caring for a patient with hyperparathyroidism.
sleeping, and thinking he’s “going crazy.” It is MOST Which symptom is MOST important for the nurse to report
important for the nurse to: to the next shift?
a. perform a complete physical and social history. a. Abdominal discomfort.
b. obtain a complete drug and alcohol history, b. Hematuria.
including reports from a drug screen. c. Muscle weakness.
c. review the significant events of the last year. d. Diaphoresis.
d. explore how he coped with the motor vehicle
crash and his friend’s death. 87. After a tonsillectomy, a nurse reviews the physician's
postoperative orders. Which of the following physician's
81. A nurse is reviewing a client's laboratory report and notes orders does the nurse question?
that the serum calcium level is 4.0 mg/dL. The nurse a. monitor for bleeding
b. suction every 2 hours
understands that which condition most likely caused this
c. give no milk or milk products
serum calcium level? d. give clear, cool liquids when awake
a. prolonged bed rest
b. renal insufficiency 88. Two days after admission, a client’s sputum culture is
c. hyperparathyroidism reported as positive for tuberculosis. While awaiting
d. excessive ingestion of vitamin D orders from the physician, the nurse should:
a. initiate measures to transfer the client to a
tuberculosis unit.
 b. institute measures to initiate airborne 94. When the nurse walks into a client’s room, the client
precautions. states, “I just love hot-blooded redheads.” The client pats
c. arrange for all of the client’s personal effects to his bed and says, “Why don’t you sit down here and get off
be decontaminated. your feet for a while.” Which of the following responses by
d. notify the client’s family that they have been the nurse is BEST?
exposed to a contagious disease. a. “I feel very uncomfortable when you make those
suggestive remarks. It makes it difficult for me to
89. A client has been newly diagnosed with hypothyroidism do my job.”
and will take levothyroxine (Synthroid) 50 mcg/day by b. “I don’t think my husband or your wife would
mouth. As part of the teaching plan, the nurse emphasizes like me doing that.”
that this medication: c. “You must be very lonesome. I’ll come back later
a. Should be taken in the morning and spend some time with you.”
b. May decrease the client’s energy level d. “I bet you flirt with all the nurses like that.”
c. Must be stored in a dark container
d. Will decrease the client’s heart rate 95. A client with amyotrophic lateral sclerosis has a
percutaneous endoscopic gastrostomy (PEG) tube for the
90. A 33-year-old woman comes to the local outpatient clinic administration of feedings and medications. Which nursing
for complaints of dizziness and palpitations. Her physical action is appropriate?
exam and laboratory results are normal. She reports that a. Pulverize all medications to a powdery condition
the company she owns is on the verge of bankruptcy. b. Squeeze the tube before using it to break up
Which of the following responses, if made to the client by stagnant liquid
the nurse, would be BEST? c. Cleanse the skin around the tube daily with
a. “When did you first notice these symptoms?” hydrogen peroxide
b. “Have you shared this information with d. Flush adequately with water before and after
anyone?” using the tube
c. “Are you concerned about your financial
difficulties?” 96. The nurse answers the psychiatric unit’s desk phone. The
d. “Would you like to discuss your situation with caller identifies himself as the husband of a patient and
me?” inquires about her condition. Which of the following
responses by the nurse is most appropriate?
91. The nurse is giving discharge teaching to a client 7 days a. “I may not deny or confirm any patient’s
post myocardial infarction. He asks the nurse why he must presence in this hospital.”
wait 6 weeks before having sexual intercourse. What is the b. “Patients are not allowed to use his phone.
best response by the nurse to this question? Please call the patient’s phone number directly.”
a. “You need to regain your strength before c. “I cannot give information over the phone. If you
attempting such exertion.” come in we can discuss her condition.”
b. “When you can climb 2 flights of stairs without d. “I will have to ask her if she wishes for me to give
problems, it is generally safe.” out that information.”
c. “Have a glass of wine to relax you, then you can
try to have sex.” 97. A nurse is assessing a client with a suspected diagnosis of
d. “If you can maintain an active walking program, hypocalcemia. Which of the following clinical
you will have less risk.”
manifestations would the nurse expect to note in the
92. A client had a radical mastectomy for cancer in her right client?
breast. After the client returns to the unit, which of the a. Twitching
following actions, if performed by the nurse, would be b. negative trousseau's sign
MOST appropriate? c. hypoactive bowel sounds
a. Position the client on her left side with her right d. hypoactive deep tendon reflexes
arm protected in a sling.
b. Position the client on her right side with her right
98. Several days after a client had a myocardial infarction, the
arm elevated.
c. Position the client in semi-Fowler’s position with physician placed him on a 2-gm sodium diet. Which of the
her right arm elevated. following selections would indicate to the nurse an
d. Position the client in the prone position with her understanding of the diet?
right arm elevated. a. Scrambled egg, orange slices, and milk.
b. Instant oatmeal, toast, and orange juice.
93. A client has been taking furosemide (Lasix) for the past
c. Poached egg, bacon, and milk
week. The nurse recognizes which finding may indicate the
client is experiencing a negative side effect from the d. Biscuit, fruit cup, and sausage.
medication?
a. Weight gain of 5 pounds 99. A client receiving parenteral nutrition (PN) complains of
b. Edema of the ankles headache. A nurse notes that the client has an
c. Gastric irritability increased blood pressure, bounding pulse, jugular vein
d. Decreased appetite distention, and crackles bilaterally. The nurse interprets
 that the client is experiencing which complication of PN
therapy.

a. sepsis
b. air embolism
c. hypervolemia
d. hyperglycemia

100. The nurse is leading a class for expectant mothers. Which

of the following comments would indicate to the nurse
that a pregnant woman understands the recommended
dietary caloric increase for pregnancy?
a. “I will need to double my calorie intake since I
am now eating for two of us.”
b. “I can add an additional 500 calories by drinking
milkshakes.”
c. “I need to add 300 calories by increasing my
intake of the four basic food groups.”
d. “I really need to watch my calorie intake so I will
not gain too much weight.”