1) የተነበበ The nurse is preparing a client who speaks little English for discharge after emergency

gallbladder surgery. Which nursing action would be most effective in helping this client
understand wound care instruction?
A) Ask frequently if the client understands the instruction
B) Ask the interpreter to relay the instructions to the client
C) Write out the instruction and have a family member read them to the client
D) Demonstrate the procedure to the client and have the client return the demonstration
2) Which of the following clients would qualify for hospice care?
A) A client with late-stage ADIS
B) A client with left –sided paralysis after a cerebrovascular accident (CVA)
C) A client who is undergoing treatment for heroin addiction.
D) A client who had coronary artery bypass surgery 2 weeks ago
3) Which of these serves as a framework for nursing education and clinical practice?
A) Scientific breakthroughs
B) Technological advance
C) Theoretical models
D) Medical practices
4) A client is hospitalized with pneumocystis carinii .pneumonia. the nurse observe that the client
had no visitors, seems withdrawn, avoids eye contact, and refuses to engaged in conversation. In
a loud and angry voice, the clients demands that the nurse leave the room. The nursing diagnosis
for this client is social isolation. Based on this diagnosis, what is an appropriate goal for this
client care?
A) Identify one way to increase social interaction
B) Report increase adaptation to changes in health status.
C) Identify at least one factor contributing to altered sexuality patterns.
D) Return a demonstration of measures that can increase independence.
5) For hospitalized clients, which statement reflects appropriate documentation in the client’s
medical record?
A) Small decubitus ulcer noted on left leg,
B) Seems to be mad at the doctor,
C) Client had a good day,
 D) Skin moist and cool,
6) A client receives meperidine (demerol), 50 mg I.M., for relief of surgical pain. 30 minutes later
the nurse asks the client if the pain is relived. Which step of the nursing process is the nurse
using?
A) Assessment
B) Nursing diagnosis
C) Implementation
D) Evaluation
7) Which assessment finding by the nurse would prohibit application of a heating pad?
A) Active bleeding
B) Reddened abscess
C) Edematous lower leg
D) Purulent wound drainage
8) A client is admitted with the following vital signs: temperature,102 0F (38.8OC); pulse, 144 BPM
and irregular, and respirations, 26 breaths/minute. Which nursing diagnosis has the
A) Decreased cardiac output
B) Ineffective thermoregulation
C) Ineffective breathing pattern
D) Altered renal tissue perfusion
9) To assess the effectiveness of cardiac compressions duringadult cardiopulmonary
resuscitation(CPR), the nursed should palpate which pulse site?
A) Radial
B) Apical
C) Carotid
D) Brachial
10) Which action by the nurse is essential when cleansing the area around a Jackson pratt wound
drain?
A) Clean from the center out in a circular
B) Remove the drain before cleancing the skin,
C) Clean briskly around the site with alcohol,
D) Wear sterile glove and a mask
11) A client with a cerebrovascular accident has a nursing diagnosis of ineffective airway clearance.
The goal for this client is to mobilze pulmonary secretions. Which actions should the nurse plan
to take to meet this goal?
A) Reposition the client every 2 hours
B) Restrict fluids to 1,000 ml in 24hr,
C) Administer oxygen by cannula as ordered
D) Keep the head of the bed at a 30-degree angle
12) A client with a fecal impaction typically exhibits which clinical manifestation?
A) Liquid or semi-liquid stools
B) Hard, brown formed stools
C) Loss of urge to defecate
D) Increased appetite
13) Two days after undergoing a modified radical mastectomy, a client tells the nurse,
“NOW I won’t be sexually attractive to my husband.” Based on this statement, which nursing
diagnosis is most appropriate?
A) Anxiety
B) Body image disturbance
C) Altered sexuality pattern
D) Ineffective individual coping
14) While preparing to start a STAT I.V. Infusion, the nurse notices the ground on the infusion
pumps plug is missing. What should the nurse do first?
A) Use the pump as is because the medication is ordered STAT,
B) Obtain another pump from central supply for the infusion
C) Tape the broken ground to the plug and use the pump.
D) Report the broken prong to the supervisor.
15) When obtaining a sterile urine specimen from an indwelling (Foley) catheter, Which nursing
action is appropriate to prevent infection?
A) Aspirate urine from the tubing port using a sterile syringe and needle.
B) Disconnect the catheter from the tubing and obtain urine.
C) Open the drainage bag and pour out some urine.
D) Wear sterile gloves when obtaining urine.
16) A client with chronic renal failure was admitted with these findings: pulse, 122 BPM;
respirations, 32 breaths/minute; blood pressure, 190/110 mmHg; neck vein distention; and
bibasilar crackles. Which nursing diagnosis should receive the highest priority?
A) Fear
B) Urinary retention
C) Fluid volume excess
D) Toileting self-care deficit
17) A client with chronic renal failure was admitted with these findings: pulse, 122 BPM;
respirations, 32 breaths/minute; blood pressure, 190/110 mmHg; neck vein distention; and
bibasilar crackles. which nursing action is most appropriate?
A) Administer diuretics as ordered
B) Administering oxygen
C) Giving health education
D) Monitoring input and output
18) A client with congestive heart failure has not slept for the past three nights due to dyspnea. The
client’s arterial blood gas (ABG) values are PH, 7.32; PaO2, 79; PaCO2,50; and HCO3, 29.
Which nursing diagnosis should receive the highest priority for this client?
A) Fatigue
B) High risk for injury
C) Activity intolerance
D) Sleep pattern disturbance
19) Which action is essential when the nurse provides a continuous parenteral feeding
A) Elevate the head of the bed.
B) Position the client on the left side.
C) Warm the formula before administering it.
D) Hang a full day’s worth of formula at one time.
20) A client is admitted with multiple decubitus ulcers. To promote healing, the nurse should
include which of these foods in the client’s diet plan?
A) Fresh orange slices
B) Ground beef patties
C) Steamed broccoli
 D) Ice cream
21) For a hospitalized client, the physician prescribes meperidine(Demerol), 75 mg I.M., every 3
hours as needed for pain. However, the client refuses to take injections. Which nursing
actions is most appropriate?
A) Administer the injection as prescribed
B) Call the physician and request an oral pain medication
C) Withhold the injection until the client understands its importance
D) Explain that no other medication can be given until the client takes the injection.
22) A client is admitted to the hospital with a productive cough, night sweats, and fever. Which
of this action is most important in the client’s initial plan care?
A) Assess the client’s temperature every 8 hours.
B) Place the clients in respiratory isolation
C) Monitor the client’s fluid intake and output.
D) Wear gloves during all clients contact
23) A client is being discharged after undergoing abdominal surgery and colostomy formation to
treat colon cancer. When planning for this client’s discharge, which nursing action is most likely
to promote continuity of care?
A) Notify the cancer society of the client’sdiagnosis.
B) Request Meals on wheels to provide adequate nutrition intake.
C) Refer the client to a home health nurse for follow-up visits to provide colostomy
care.
D) Ask an occupational therapist to evaluate the client at home
24) What is a common goal of discharge planning in all care settings?
A) Prolong hospitalization until the client can function independently.
B) Teach the client how to perform self-care.
C) Provide the financial resources needed to ensure proper care.
D) Prevent the need for further medical follow-up.
25) A client is receiving an I.V. infusion of dextrose 5% in water and Ringer’s lactate solution at
125 ml/hr to treat a fluid volume deficit. Which of these signs indicates a need for additional
I.V. fluids?
A) Serum sodium level of 135 mEq/litter
 B) Temperature of 99.60F (37.50C)
C) Neck vein distention
D) Dark amber urine
26) A client with congestive heart failure has been receiving an I.V. infusion at 125 ml/hr. Now
the client is short of breath, and the nurse notes bilateral crackles, neck vein distention, and
tachycardia. What should the nurse do first?
A) Notify the physician
B) Discontinue the infusion.
C) Administer the prescribed diuretic.
D) Slow the infusion and notify the physician.
27) After a bronchoscopy, the client must receive nothing by mouth until the gag reflex returns.
What is the best way to assess for return of the gag reflex?
A) Instruct the client to cough
B) Ask the client to extend the tongue
C) Tickle the uvula with a tongue blade
D) Observe while the client swallows sips of water
28) After a cerbrovascular accident (CVA), a client develops aphasia. Which assessment finding
most typifies aphasia?
A) Arm and leg weakness.
B) Absence of gag reflex.
C) Difficulty with swallowing.
D) Inability to speak clearly.
29) Each morning in the unit, the head nurse assigns clients and additional tasks to the nurses to
be completed that day. During the shifts, a crisis develops and one of the staff nurses does
not complete the additional tasks. The next day, the staff nurse is reprimanded. When the
staff nurse tries to explain, the head nurse replies that the tasks should have been completed
anyway. Which these leadership styles is the head nurse exhibiting?
A) Democratic
B) Permissive
C) Laissez-faire
D) Authoritian
30) Which of the following addresses the client’s right to information, informed consent, and
treatment refusal?
A) Standards of nursing practice
B) Patient Bill of right
C) Nurse practice Act
D) Code for nurses
31) An employer has established a physical exercise area in the workplace and encourages all
employees to used it. This is an example of what level of health promotion.
A) Primary prevention
B) Secondary prevention
C) Tertiary prevention
D) passive prevention
32) A client is admitted with fatigue, anorexia, weight loss, and inability to sleep that started 1
month after the death of the client’s spouse. Which nursing diagnosis is most appropriate for
this client?
A) Activity intolerance
B) Dysfunctional grieving
C) Altered role performance
D) Impaired physical mobility
33) A client is admitted completely immobilized by an acute exacerbation of multiple sclerosis.
Two days after admission, the client cries frequently and refuses to see family members. For
this client, the nurse identifies a nursing diagnosis of hopelessness. To address this diagnosis,
the nurse should include which intervention in the client’s plan of care?
A) Obtain an order for a tranquilizer
B) Limit visitors to 15minutes per day.
C) Encourage the client to verbalize feelings
D) Reinforce the client’s responsibility to the family.
34) Which question by the nurse would be most helpful when obtaining a health history from a
client admitted with acute chest pain?
A) Do you need anything now?
B) Why do you think you had a heart attack?
 C) What were you doing when the pain started?
D) Has anyone in your family been sick lately?
35) When caring for a client and following universal precautions, what is the nurse’s primary
responsibility?
A) Wear gloves whenever in contact with the client,
B) Consider all body substances potentially infectious.
C) Place a body substance isolation sign on the client’s door.
D) Wear a gown and gloves when caring for a client in respiratory isolation.
36) Which intervention has the highest priority when a nurse is caring for a client receiving a
blood transfusion?
A) Instruct the client to notify the nurse if itching, swelling, or dyspnea occurs.
B) Inform the client that the transfusion usually takes 11/2 to 2 hours.
C) Document the blood administration in the client care record.
D) Assess the client’s vital signs when the transfusion is completed
37) The physician prescribes the following preoperative medications to a client for I.M.
administration: meperidine(Demerol), 50 mg; hydroxyzine (vistaril), 25 mg; and
glycopyrrolate(robinui), 0.3 mg. The medications are dispensed as follows: meperidine,
100mg/ml; hydroxyzine, 100mg/2ml; and glycopyrrolate, 0.2 mg/ml. how many milliliters,
in total, should the nurse administer?
A) 5ml
B) 4.5ml
C) 2.5ml
D) 2.0ml
38) Which statement accurately characterizes the Z-track method for I.M. injections?
A) The skin is released before the needle is withdrawn.
B) The deltoid muscle is the preferred site for administration.
C) Aspiration is not necessary because the needle is inserted deep in the muscle
layer.
D) The needle remains in place for 10 seconds after injection to allow the medication
to disperse.
39) A client with shock due to hemorrhage has this vital signs: temperature 97.60F (36.40C); pulse,
140 beats/minute; respiration, 28 breaths/minute; and blood pressure, 60/30 mmHg. For this
client, the nurse should question which physician order?
A) Monitor urine output every hour.
B) Infuse I.V. fluids at 83 ml/hr
C) Administer oxygen by nasal cannula at 3 litter/minute
D) Draw specimens for hemoglobin and hematocrit every 6 hr
40) Before performing a venipuncture to initiate continous intravenous (IV) therapy, a nurse would:
A) Apply a tourniquet below the chosen vein site
B) Inspect the IV solution for particles or contamination
C) Secure an armboard to the joint located above the IV site
D) Place a cool compress over the vien
41) Which assessment is most important for the nurse to make before advancing a client from liquid
to solid food?
A) Food preferences
B) Appetite
C) Presence of bowel sound
D) Chewing ability
42) What method would a nurse use to most accurately assess the effectiveness of a weight loss diet
for an obese clent?
A) Daily weights
B) Serum protein levels
C) Daily calorie counts
D) Daily intake and output
43) A nurse performs a fingerstick glucose test on a client receiving total parenteral nutrition (TPN).
Results show the client’s glucose level to be greater than 400 mg/dL. What nursing action is
most appropriate at this time?
A) Stop the TPN
B) Decrease the flow rate of the TPN
C) Administer insulin
D) Notify the physician
44) A nurse is assessing a preoperative client. Which of the following questions will help the nurse
determine the client’s risk for developing malignant hyperthermia postoperatively?
A) “What is your normal body temperature?”
B) “Do you experience for frequent infections?”
C) “do you have a family history of problems with general anesthesia?”
D) “have you ever suffered from heat exhaustion or heat stroke?”
45) A nurse has just finished assisting a physician in placing a central intravenoud (IV) line. Which
of the following is a priority nursing intervention?
A) Obtain a temperature to monitor for infection
B) Monitor the blood pressure (BP) to assess for fluid volume overload
C) Label the dressing with the date and time of catheter ncertion
D) Prepare the client for a chest x-ray examination
46) A client with diabetes mellitus has a blood glucose level of 644 mg/dL. The nurse interprets that
this client is most at risk of developing which type of acid-base imbalance?
A) Respiratory acidosis
B) Respiratory Alkalosis
C) Metabolic acidosis
D) Metabolic Alkalosis
47) A nurse is reviewing the client’s most recent blood gas results and the results indicate a PH of
7.42, PaCO2 of 31 mmHg, and HCO3 mEq/L. The nurse interprets these results as indicative of
which acid-base imbalance?
A) Uncompensated metabolic alkalosis
B) Compensated metabolic acidosis
C) Uncompensated respiratory acidosis
D) Compensated respiratory alkalosis
48) A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurses
assesses the client for symptoms of which acid-base disorder?
A) metabolic acidosis
B) metabolic alkalosis
C) respiratory acidosis
D) respiratory alkalosis
49) a nurse is caring for a client with late stage salicylate poisoning who is experiencing metabolic
acidosis. The client has a chemistry blood profile drawn. The nurse anticipates that, which
laboratory value is related to the client’s acid-base disturbance?
A) Sodium of 145mEq/L
B) Magnesium 2.0 mEq/L
C) Potassium 5.2 mEq/l
D) Phosphorus 2.3 mEq/L
50) A 1000-mL intravenous (IV) solution of normal saline solution 0.9% is prescribed for the client.
The nurse understands that, which of the following is not a characteristic of this type of solution?
A) Is isotonic with plasma and other body fluids
B) Is hypotonic with the plasma and other body fluids
C) Does not affect plasma osmolarity
D) Is the same solution as sodium chloride 0.9%