Saunders Practice Tests

Test #1
Questions 1-200
Pages 2-35

Test #2
Questions 1-200
Pages 36 - 71

Test #3
Questions 1-200
Pages 72-106

Test #4
Questions 1-200
Pages 107 - 146

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 Saunders Exam Practice Questions Test #1
1. A client is diagnosed with cancer and is told that surgery followed by chemotherapy will be
necessary. The client states to the nurse “I have read a lot about complementary therapies. Do you
think I should try any?” The nurse should respond by making which appropriate statement?
a. “I would try anything that I could if I had cancer”
b. “No, because it will interact with the chemotherapy
c. “Tell me what you know about complementary therapies”
d. “You need to ask your primary health care provider about it”

2. The nurse is preparing to assist a client of orthadox jewish faith with eating lunch. A kosher meal is
delivered to the client. Which nursing action is appropriate when assisting the client with the meal?
a. Unwrapping the eating utensils for the client
b. Replacing the plastic utensils with metal utensils
c. Carefully transferring the food from paper plates to glass plates
d. Allowing the client to unwrap the utensils and prepare his own meal for eating

3. The nurse is caring for a group of clients who are taking herbal medications at home. Which client
should be given instructions with regard to avoiding the use of herbal medications
a. A 60 year old male client with rhinitis
b. A 24 year old male client with a lower back injury
c. A 10 year old female client with a UTI
d. A 45 year old female with a history of migraine headaches

4. The client asks the nurse about various herbal therapies available for the treatment of insomnia. The
nurse should encourage the client to discuss the use of which product with the primary health care
provider
a. Garlic
b. Valerian
c. Lavender
d. Glucosamine

5. The nurse is assisting with collecting data from an african american client admitted to the ambulatory
care unit who is scheduled for a hernia repair. Which information about the client is of lowest
priority during the data collection?
a. Respiratory
b. Psychosocial
c. Neurological
d. Cardiovascular

6. The nurse is planning to reinforce nutrition instructions to an African American client. When
reviewing the plan, the nurse is made aware that which food may be a common dietary practice of
clients with African American heritage?
a. Raw fish
b. Red meat
c. Fried foods
d. Rice as the basis for all meals

7. The nurse consults with a dietician regarding the dietary preferences of an Asian American client.
Which food should the nurse suggest to include in the plan?
a. Rice
b. Fruits
c. Red meat
d. Fried foods
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8. An antihypertensive medication has been prescribed for a client with hypertension. The client tells
the nurse that she would like to take an herbal substance to help lower her blood pressure. Which
statement by the nurse is most important to provide to the client?
a. “Herbal substances are not safe and should never be used”
b. “I will teach you how to take your blood pressure so that it can be monitored closely”
c. “You will need to talk to your primary health care provider before using an herbal substance”
d. “If you take an herbal substance, you will need to have your blood pressure checked
frequently”

9. A Hispanic African mother brings her child to the clinic for an examination. Which is the most
important when gathering data about the child?
a. Avoiding eye contact
b. Using body language only
c. Avoiding speaking to the child
d. Touching the child during the examination

10. A nursing student is asked to identify the practices and beliefs of the amish society. Which should
the student identify? Select all that apply
a. Many choose not to have health insurance
b. They believe health is a gift from God
c. The authority of women is equal to that of men
d. They remain secluded and avoid helping others
e. They use both traditional and alternative health care, such as healers, herbs, and massage
f. Funerals are conducted in the home without a eulogy, flower decorations, or any other
display. Caskets are plain and simple, without adornment

11. Which identifies accurate nursing documentation notations? Select all that apply
a. The client slept through the night
b. Abdominal wound dressing is dry and intact without drainage
c. The client seemed angry when awakened for vital sign measurement
d. The client appears to become anxious when it is time for respiratory treatments
e. The client’s left lower medial leg wound is 3cm in length without redness, drainage or edema

12. The LPN enters a client’s room and finds the client laying on the bathroom floor. The LPN calls the
RN, who checks the client thoroughly and then assists the client back into bed. The LPN completes
an incident report, and the nursing supervisor and primary health care provider are notified of the
incident. Which is the next nursing action regarding the incident?
a. Place the incident report in the client’s chart
b. Make a copy of the incident report for the PHCP
c. Document a complete entry in the client’s record concerning the incident
d. Document in the client’s record that an incident report has been completed

13. An unconscious client, bleeding profusely, is brought to the ED after a serious accident. Surgery is
required immediately to save the client’s life. With regard to informed consent for the surgical
procedure, which is the best action?
a. Call the nursing supervisor to initiate a court order for the surgical procedure
b. Try calling the client’s spouse to obtain telephone consent before the surgical procedure
c. Ask the friend who accompanied the client to the ED to sign the consent form
d. Transport the client to the operating department immediately without obtaining an informed
consent

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14. The nurse arrives at work and is told to report (float) to the pediatric unit for the day because the unit
is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the
pediatric unit. Which is the appropriate nursing action?
a. Call the hospital lawyer
b. Call the nursing supervisor
c. Refuse to float to the pediatric unit
d. Report to the pediatric unit and identify tasks that can be safely performed

15. The nurse enters a client’s room and notes that the client’s lawyer is present and that the client is
preparing a living will. The living will requires that the client’s signature be witnessed, and the client
asks the nurse to witness the signature. Which is the appropriate nursing action?
a. Decline to sign the will
b. Sign the will as a witness to the signature only
c. Call the hospital lawyer before signing the will
d. Sign the will, clearly identifying credentials and employment agency

16. The nurse finds the client lying on the floor. The nurse calls the RN, who checks the client and then
calls the nursing supervisor and the PHCP to inform them of the occurrence. The nurse completes the
incident report for what purpose?
a. Providing clients with necessary stabilizing treatments
b. A method of promoting quality care and risk management
c. Determining the effectiveness of interventions in relation to outcomes
d. The appropriate method of reporting to local, state and federal agencies

17. The nurse observes that a client received pain medication one hour ago from another nurse, but the
client still has severe pain. The nurse has previously observed this same occurrence several times.
Based on the nurse practice act, the observing nurse should plan to take which action?
a. Report the information to the police
b. Call the impaired nurse organization
c. Talk with the nurse who gave the medication
d. Report the information to a nursing supervisor

18. A client has died, and the nurse asks a family member about the funeral arrangements. The family
member refuses to discuss the issue. Which is the appropriate nursing action?
a. Show acceptance of feelings
b. Provide information needed for decision making
c. Suggest a referral to a mental health professional
d. Remain with the family member without discussing funeral arrangements

19. A nurse lawyer provides an education session to the nursing staff regarding client rights with
emphasis of invasion of client rights. The nurse lawyer asks a staff nurse to identify a situation that
represents an example of invasion of client privacy. Which situation, if identified by the student,
indicates an understanding of a violation of this client’s right?
a. Threatening to place a client in restraints
b. Performing a surgical procedure without consent
c. Taking photographs of a client without consent
d. Telling the client that he or she cannot leave the hospital

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20. An older woman is brought to the ED. When caring for the client, the nurse notes old and new
ecchymotic areas on both of the client’s arms and buttocks. The nurse asks the client how the bruises
were sustained. The client, although reluctant, tells the nurse in confidence that her daughter
frequently hits her if she gets in the way. Which is the appropriate nursing response?
a. “I have a legal obligation to report this type of abuse”
b. “I promise I won’t tell anyone, but let’s see what we can do about this”
c. “Let’s talk about this in ways that will prevent your daughter from hitting you”
d. “This should not be happening. If it happens again, you must call the ED”

21. The nurse is recording a nursing hands-off (end of shift) report for a client. Which information needs
to be included?
a. As-needed medications given that shift
b. Normal vital signs that have been normal since admission
c. All of the tests and treatments the client has had since admission
d. Total number of scheduled medications that the client received on that shift

22. The nurse is planning the client assignments for the day. Which is the most appropriate assignment
for the unlicensed assistive personnel?
a. A client who requires wound irrigation
b. A client who requires frequent ambulation
c. A client who is receiving continuous tube feedings
d. A client who requires frequent vital signs after a cardiac catheterization

23. The nurse employed in a LTC facility is planning the client assignments for the shift. Which client
should the nurse assign to the unlicensed assistive personnel?
a. A client who requires 24 hour urine collection
b. A client who requires twice daily dressing changes
c. A client with DM who requires daily insulin and the reinforcement of dietary measures
d. A client who has been placed on a bowel management program and requires rectal
suppositories and a daily enema

24. The nurse is assigned to care for four clients. When planning client rounds, which client should the
nurse check first?
a. A client in skeletal traction
b. A client who is dependent on a ventilator
c. A postoperative client preparing for discharge
d. A client admitted during the previous shift with a diagnosis of gastroenteritis

25. The nurse employed in an ED is assigned to assist with the triage of clients arriving to ED. The nurse
should assign priority to which client?
a. A client complaining of a muscle ache, headache and malaise
b. A client who twisted their ankle when they fell in-line skating
c. A client with a minor laceration on the index finger sustained while cutting an eggplant
d. A client with chest pain who states that they just ate pizza that was made with a very spicy
sauce

26. The nurse is educating a new nurse about mass casualty events (disasters). Which statement by the
new nurse indicates a need for further teaching? Select all that apply
a. “An event is termed a mass casualty when it overwhelms local medical capabilities”
b. “Mass casualty events do not require an increase in the number of staff that are needed”
c. “A mass casualty event occurs only within the health care facility and could endanger staff”
d. “Mass casualty events may require the collaboration of many local agencies to handle the
situation”
e. “A mass casualty event occurs if a fight between visitors occurs in the ED”
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27. The nurse is attending an agency orientation meeting about the nursing model of practice
implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The
nurse determines that which describes the team-based model of nursing practice?
a. A task approach method is used to provide care to clients
b. Managed care concepts and tools are used when providing client care
c. Nursing staff are led by the nurse when providing care to a group of clients
d. A single RN is responsible for providing nursing care to a group of clients

28. A client experiences a cardiac arrest. The nurse leader quickly responds to the emergency and
assigns clearly defined tasks to the work group. In this situation, the nurse is implementing which
leadership style?
a. Autocratic
b. Situational
c. Democratic
d. Laissez-faire

29. The nurse has delegated several nursing tasks to staff members. Which is the nurse’s primary
responsibility after the delegation of tasks?
a. Document that the task was completed
b. Assign the tasks that were not completed to the next nursing shift
c. Allow each staff member to make judgements when performing the tasks
d. Perform follow up with each staff member regarding the performance and outcome of the
task

30. The nurse is assigned to care for four clients. When planning client rounds, which client should the
nurse collect data from first?
a. A client scheduled for a chest x-ray
b. A client requiring daily dressing changes
c. A postoperative client preparing for discharge
d. A client receiving oxygen who is having difficulty breathing

31. The nurse is caring for a client with kidney failure notes that the client has dyspnea and crackles are
heard when listening to breath sounds in the lungs. Which additional sign/symptom should the nurse
expect to note in this client?
a. Rapid weight loss
b. Flat hand and neck veins
c. A weak and thready pulse
d. An increase in blood pressure

32. The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing
which client is at risk for potassium deficit?
a. The client with addison's disease
b. The client with metabolic acidosis
c. The client with an intestinal obstruction
d. The client receiving nasogastric suction

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33. The nurse reviews a client’s electrolyte results and notes a potassium level of 5.5 mEq/L. The nurse
understands that a potassium value at this level would be noted with what condition?
a. Diarrhea
b. Traumatic Burn
c. Cushing’s Syndrome
d. Overuse of laxatives

34. The nurse reviews a client’s electrolyte results and notes that the potassium level is 5.4 mEq/L. What
should the nurse look for on the cardiac monitor as a result of this laboratory value?
a. ST elevation
b. Peaked P waves
c. Prominent U waves
d. Narrow, peaked T waves

35. The nurse is reading the primary health care providers progress notes in the client’s record and sees
that the PHCP has documented “insensible fluid loss of approximately 800ml daily” which client is
at risk for this loss?
a. The client with a draining wound
b. The client with a urinary catheter
c. The client with a fast respiratory rate
d. The client with a NG tube to low suction

36. The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing
which client is at the least likely risk for the development of third-spacing?
a. The client with sepsis
b. The client with cirrhosis
c. The client with kidney failure
d. The client with DM

37. The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing
that which client is at risk for fluid volume deficit
a. The client with cirrhosis
b. The client with an ileostomy
c. The client with heart failure
d. The client with decreased kidney function

38. The nurse is caring for a client who has been taking diuretics on a long-term basis. Which finding
should the nurse expect to note as a result of this long term use?
a. Gurgling respirations
b. Increased BP
c. Decreased hematocrit levels
d. Increased specific gravity of urine

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39. The nurse reviews electrolyte values and notes a sodium level of 130 mEq/L. The nurse expects this
sodium level would be noted in a client with which condition?
a. The client with watery diarrhea
b. The client with diabetes insipidus
c. The client with an inadequate daily water intake
d. The client with the syndrome of inappropriate secretion of antidiuretic hormone

40. The nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat
hand and neck veins. The nurse suspects hyponatremia. Which additional signs and symptoms
should the nurse expect to note in this client if hyponatremia is present?
a. Intense thirst
b. Slow bounding pulse
c. Dry mucous membranes
d. Postural blood pressure changes

41. The nurse is caring for a client with a diagnosis of hyperparathyroidism. Laboratory studies are
performed and the serum calcium level is 12.0 mg/dL. Based on this lab value, the nurse should take
which action?
a. Document the value in the client’s record
b. Inform the RN of the lab value
c. Place the lab result form in the client’s record
d. Reassure the client that the lab value is normal

42. The nurse reviews the client's serum calcium level and notes that the level is 8.0 mg/dL. The nurse
understands which condition would cause this serum calcium level?
a. Prolonged bed rest
b. Adrenal insufficiency
c. Hyperparathyroidism
d. Excessive ingestion of Vitamin D

43. The nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which signs and
symptoms would be an indication of this electrolyte imbalance?
a. Twitching
b. Positive trousseau's sign
c. Hyperactive bowel sounds
d. Generalized muscle weakness

44. The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse
should tell the client which food item is least likely to contain calcium?
a. Milk
b. Butter
c. Spinach
d. Collard greens

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45. The nurse is caring for a client with hyperparathyroidism and notes that the client’s serum calcium
level is 13 mg/dL. Which prescribed medication should the nurse plan to assist in administering to
the client?
a. Calcitonin
b. Calcium chloride
c. Calcium gluconate
d. Large doses of vitamin D

46. A client has the following laboratory values: a pH of 7.55, and HCO3- level of 22 mEq/L, and a
PCO2 of 30 mm Hg. Which action should the nurse plan to take?
a. Perform the allan’s test
b. Prepare the client for dialysis
c. Administer insulin as prescribed
d. Encourage the client to slow down breathing

47. The nurse is told that the ABG results indicate a pH of 7.50 and a PCO2 of 32 mm Hg. The nurse
determines that these results are indicative of what acid-base imbalance?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis

48. A client is scheduled for blood to be drawn from the radial artery for an ABG determination. The
nurse assists with performing Allan’s test before drawing blood to determine the adequacy of which?
a. Ulnar circulation
b. Carotid circulation
c. Femoral circulation
d. Brachial circulation

49. The nurse is caring for a client with a NG tube that is attached to low suction. The nurse monitors the
client closely for what acid-base disorder that is most likely to occur in this situation?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis

50. The nurse is caring for a client with severe diarrhea. The nurse monitors the client closely,
understanding that the client is at risk for developing what acid-base disorder?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis

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51. The nurse observes that a client with diabetic ketoacidosis is experiencing abnormally deep, regular,
rapid respirations. How should the nurse correctly document this observation in the medical record
a. Apnea
b. Bradypnea
c. Cheyne stokes
d. Kussmaul’s respirations

52. The nurse is caring for a client with a diagnosis of COPD. the nurse should monitor the client for
which acid-base imbalance?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis

53. Which clients would the nurse determine is at risk for development of metabolic alkalosis? Select all
that apply
a. Client with emphysema
b. Client who is hyperventilating
c. Client with chronic kidney disease
d. Client who has been vomiting for 2 days
e. Client receiving oral furosemide 40mg daily
f. Client admitted with ASA overdose

54. The nurse is caring for a client with respiratory insufficiency. The ABG results indicate a pH of 7.50
and a PCO2 of 30 mm Hg, and the nurse is told that the client is experiencing respiratory alkalosis.
Which additional laboratory value should the nurse expect to note?
a. Sodium level of 145 mEq/L
b. Potassium level of 3.0 mEq/L
c. Magnesium level of 1.3 mEq/L
d. Phosphorus level of 3.0 mg/dL

55. The RN reviews the results of the ABG values with the LPN and tells the LPN that the client is
experiencing respiratory acidosis. The LPN should expect to note which on the laboratory result
report?
a. pH 7.50, PCO2 52 mm Hg
b. pH 7.35, PCO2 40 mm Hg
c. pH 7.25, PCO2 50 mm Hg
d. pH 7.50, PCO2 30 mm Hg

56. A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a PT of
35 seconds and an INR of 3.5. On the basis of these laboratory values, the nurse anticipates which
prescription?
a. Adding a dose of heparin sodium
b. Holding the next dose of warfarin
c. Increasing the next dose of warfarin
d. Administering the next dose of warfarin

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57. A LPN is precepting a student assigned to care for a client with chronic pain. Which statement if
made by the student, indicates the need for further teaching regarding pain management?
a. I will be sure to ask my client what their pain level is on a scale of 0-10
b. I know that i should follow-up after giving medications to make sure it is effective
c. I know that the pain in the older client might manifest as sleep disturbance or depression
d. I will be sure to cue in to any indicators that the client may be exaggerating pain

58. A client has been admitted to the hospital for a UTI and dehydration. The nurse determines that the
client has received adequate volume replacement if the blood urea nitrogen level drops to what
value?
a. 3 mg/dL
b. 15 mg/dL
c. 29 mg/dL
d. 35 mg/dL

59. A LPN is explaining the appropriate methods for measuring an accurate temperature to an unlicensed
assistive personnel. Which method, if noted by the UAP as being an appropriate method, indicates
the need for further teaching?
a. Taking rectal temperature for a client who has recently undergone nasal sx
b. Taking an oral temperature for a client with a cough and nasal congestion
c. Taking an axillary temperature on a client who just consumed hot coffee
d. Taking a temporal temperature on the neck behind the ear on a client who is diaphoretic

60. A client is receiving a continuous IV infusion of heparin sodium to treat DVT. The clients activated
partial thromboplastin (aPTT) time is 65 seconds. The LPN reviews the laboratory results with the
RN anticipating which action is needed?
a. Discontinuing heparin infusion
b. Increasing the rate of the heparin infusion
c. Decreasing the rate of the heparin infusion
d. Leaving the rate of the heparin infusion as it is

61. A client with a hx of cardiac disease is due for a morning dose of furosemide. Which serum
potassium level, if noted in the client’s lab report, should be reported before administering the dose
of furosemide?
a. 3.2 mEq/L
b. 3.8 mEq/L
c. 4.2 mEq/L
d. 4.8 mEq/L

62. Several lab tests are prescribed for a client, and the nurse reviews the results of the tests. Which lab
test result should the nurse report? Select all that apply
a. Platelets 35,000 mm3
b. Sodium 150 mEq/L
c. Potassium 5.0 mEq/L
d. Segmented neutrophils 40%
e. Serum creatinine 1 mg/dL
f. WBC 3000 mm3

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63. The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on
the client’s medication and determines it is necessary to consult with the RN if the client is also
taking which medications? Select all that apply
a. Warfarin
b. Glimepiride
c. Amlodipine
d. Simvastatin
e. Hydrochlorothiazide

64. A client with DM has a glycosylated hemoglobin A1C level of 9%. On the basis of this test result,
the nurse plans to reinforce teaching the client about the need for which measure?
a. Avoiding infection
b. Taking inadequate fluids
c. Preventing and recognizing hypoglycemia
d. Preventing and recognizing hyperglycemia

65. The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse
would suggest to the RN the need for implementing neutropenic precautions if the client;s WBC
count was which value?
a. 2000 mm3
b. 5800 mm3
c. 8400 mm3
d. 11500 mm3

66. A client brought to the ED states that he has accidentally been taking two times his prescribed dose
of warfarin for the past week. After noticing the client has no evidence of obvious bleeding, the
nurse plans to assist the RN with which action?
a. Administering an antidote
b. Drawing a sample for type and crossmatch and transfuse the client
c. Drawing a sample for an aPTT level
d. Drawing a sample for PT and INR

67. A LPN is caring for a postoperative client who is receiving demand dose hydromorphone via PCA
pump for pain control. The nurse enters the client’s room and finds the client drowsy and records the
following vitals: temperature 36.2, pulse 53 BPM, BP 101/58, RR 11, SpO2 93% on 3L of O2 via
nasal cannula. Which action should the nurse take first?
a. Document the findings
b. Attempt to arouse the client
c. Contact the RN immediately
d. Check the medication administration record on the PCA pump

68. An adult female client has a hemoglobin level of 10.8 g/dL. The nurse interprets that this result is
most likely caused by which condition noted in the client’s hx?
a. Dehydration
b. Heart failure
c. Iron deficiency anemia
d. COPD

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69. A client with a hx of GI bleeding has a platelet count of 300,000 mm3. The nurse should take which
action after seeing the lab results?
a. Report the abnormally low count
b. Report the abnormally high count
c. Place the client on bleeding precautions
d. Place the normal report in the client's medication record

70. A client with DM has a blood sample drawn for determination of a fasting blood glucose level. When
reviewing the client’s results, the nurse determines that which requires a call to the primary health
care provider for intervention?
a. 75 mg/dL
b. 92 mg/dL
c. 120 mg/dL
d. 240 mg/dL

71. A client is having problems with blood clotting. Which food item should the nurse encourage the
client to eat?
a. Legumes
b. Citrus fruit
c. Vegetable oils
d. Green, leafy vegetables

72. When reinforcing dietary instructions to a client with IBS who’s primary symptom is alternating
constipation and diarrhea, the nurse would tell the client which foods are the best to include in the
diet for this disorder? Select all that apply
a. Beans
b. Apples
c. Cabbage
d. Brussel sprouts
e. Whole grain bread

73. A hospitalized client is a lacto-vegetarian. Which food item should the nurse remove from the meal
tray?
a. Eggs
b. Milk
c. Cheese
d. Broccoli

74. A low-sodium diet has been prescribed for a client with hypertension. Which food selected from the
menu by the client indicates an understanding of this diet?
a. Baked turkey
b. Tomato soup
c. Boiled shrimp
d. Chicken gumbo

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75. The nurse is providing dietary instructions to a client with gout. The nurse should tell the client to
avoid which food item?
a. Scallops
b. Chocolate
c. Cornbread
d. Macaroni products

76. A clear liquid diet has been prescribed for a client with gastroenteritis. Which item is appropriate to
offer the client?
a. Soft custard
b. Orange juice
c. Clam chowder
d. Fat free beef broth

77. A client with heart disease is instructed regarding a low-fat diet. The nurse determines that the client
understands the diet if the client states to avoid which food item?
a. Apples
b. Cheese
c. Oranges
d. Skim milk

78. The nurse reinforces instructions to a client to increase the amount of riboflavin in the diet. The nurse
should tell the client to select which food item that is high in riboflavin?
a. Milk
b. Tomatoes
c. Citrus fruits
d. Green, leafy vegetables

79. A client with a burn injury is transferred to the nursing unit, and a regular diet has been prescribed.
The nurse encourages the client to eat which dietary items to promote wound healing?
a. Veal, potatoes, gelatin and orange juice
b. Chicken breast, broccoli, strawberries, and milk
c. Peanut butter and jelly sandwich, cantaloupe and tea
d. Spaghetti with tomato sauce, garlic bread, and ginger ale

80. The nurse has completed diet teaching for a client who has been prescribed a low-sodium diet to treat
HTN. The nurse determines that there is a need for further teaching when the client makes which
statement?
a. This diet will help lower my BP
b. Fresh foods such as fruits and vegetables are high and sodium
c. This diet is not a replacement for my antihypertensive medications
d. The reason I need to lower my salt intake is to reduce fluid retention

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81. The nurse is assisting with caring for a client who will receive a unit of blood. Just before the
infusion, is is most important for the nurse to check which item?
a. Vital signs
b. Skin colour
c. Oxygen saturation
d. Latest hematocrit level

82. A client who is receiving a blood transfusion pushes the call light for the nurse. When entering the
room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching.
How should the nurse correctly interpret these findings?
a. Bacteremia
b. Fluid overload
c. Hypovolemic shock
d. Transfusion reaction

83. A client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse
sends the blood bag that was used for the client to which area?
a. The pharmacy
b. The laboratory
c. The blood bank
d. The risk-management department

84. The nurse takes a client’s temperature before giving a blood transfusion. The temperature is 100 F
(37.7 C) orally. The nurse reports the finding to the registered nurse and anticipates that which action
will take place?
a. The transfusion will begin as prescribed
b. The transfusion will begin after the administration of an antihistamine
c. The transfusion will begin after the administration of 650 mg of acetaminophen
d. The blood will be held, and the PHCP will be notified

85. Which of these clients is/are most likely to develop fluid (circulatory) overload? Select all that apply
a. A premature infant
b. A 101 year old man
c. A client with heart failure
d. A client with DM
e. A client receiving renal dialysis
f. A 29 year old client with pneumonia

86. A client has a prescription to receive 1000 mL of 5% dextrose in 0.45% sodium chloride. After
gathering the appropriate equipment, the nurse takes which action first before spiking the IV bag
with the tubing?
a. Uncaps the distal end of the tubing
b. Upcaps the spike portion of the tubing
c. Opens the roller clamp on the IV tubing
d. Closes the roller clamp on the IV tubing

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87. The nurse is doing a routine assessment of a client’s peripheral IV site. The nurse notes that the site
is cool, pale and swollen and that the IV has stopped running. The nurse determines that which has
probably occurred?
a. Phlebitis
b. Infection
c. Infiltration
d. Thrombosis

88. The nurse is assigned to care for a client with a peripheral IV infusion. The nurse is providing
hygiene care to the client and should avoid which while changing the client’s hospital gown?
a. Using a hospital gown with snaps at the sleeves
b. Disconnecting the IV tubing from the catheter in the vein
c. Checking the IV flow rate immediately after changing the hospital gown
d. Putting the bag and tubing through the sleeve, followed by the client’s arm

89. The nurse is making a worksheet and listing the tasks that need to be performed for assigned adult
clients during the shift. The nurse writes on the plan to check the IV of an assigned client who is
receiving fluid replacement therapy how frequently?
a. Every hour
b. Every 2 hours
c. Every 3 hours
d. Every 4 hours

90. The nurse is checking the insertion site of a peripheral IV catheter. The nurse notes the site to be
reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter.
The nurse interprets that this is likely the result of which?
a. Phlebitis of the vein
b. Infiltration of the IV line
c. Hypersensitivity to the IV solution
d. An allergic reaction to the IV catheter material

91. The nurse has been instructed to remove an IV line. The nurse removes the catheter by withdrawing
the catheter while applying pressure to the site with which item?
a. Band-aid
b. Alcohol swab
c. Betadine swab
d. Sterile 2x2 gauze

92. The nurse is preparing an IV solution and tubing for a client who requires IV fluids. While preparing
to prime the tubing, the tubing drops and hits the top of the medication cart. The nurse should plan to
take which action?
a. Change the IV tubing
b. Wipe the tubing with betadine
c. Scrub the tubing with an alcohol swab
d. Scrub the tubing before attaching it to the IV bag

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93. A client is going to be transfused with a unit of packed RBC. The nurse understands that it is
necessary to remain with the client for what time period after the transfusion is started?
a. 5 minutes
b. 15 minutes
c. 30 minutes
d. 45 minutes

94. The nurse is assisting with caring for a client who is receiving a unit of packed RBC. The nurse
should tell the client that it is the most important to report which signs immediately?
a. Sore throat or earache
b. Chills, itching or rash
c. Unusual sleepiness or fatigue
d. Mild discomfort at the catheter site

95. The nurse is assisting with caring for a client who has received a transfusion of platelets. The nurse
determines that the client is benefiting most from this therapy if the client exhibits which finding?
a. An increased hematocrit level
b. An increased hemoglobin level
c. A decline of the temperature to normal
d. A decrease in oozing from puncture sites and gums

96. The nurse is assisting to perform a focused data collection process on a client who is complaining of
symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of
data collection? Select all that apply
a. Listening to lung sounds
b. Obtaining the client’s temperature
c. Checking the strength of peripheral pulses
d. Obtaining information about the client’s respirations
e. Performing a musculoskeletal and neurological examination
f. Asking the client about a family hx of any illness or disease

97. A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which signs
should the nurse expect to note in the health record when collecting data related to the respiratory
system for this client?
a. Stridor and cyanotic lips
b. Diminished breath sounds and fever
c. Wheezes and use of accessory muscles
d. Pleural friction rub and inspirational chest pain

98. The nurse is reviewing the client’s health record and notes that the client elicited a positive romberg
sign. Based on this finding, the nurse should institute which intervention?
a. Collect data to determine factors for fall risk
b. Close the blinds and turn off the overhead light
c. Instruct the client to ask for assistance when getting up to walk
d. Teach the client to lift legs high while walking, as if walking over planks
e. Ensure the client is upright when eating and swallows twice after each bite

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99. The nurse learns in report that a client is exhibiting cheyne-stokes respirations. Based on this data,
which action is most appropriate for the nurse to take initially?
a. Listen to the client’s heart sounds
b. Determine whether the client has a pulse deficit
c. Instruct the client to use an incentive spirometer
d. Determine the client’s ability to follow verbal commands

100. The nurse notes documentation that a client has conductive hearing loss. The nurse plans care
knowing that this kind of hearing loss can be caused by which circumstances? Select all that apply
a. A defect in the cochlea
b. Acute otitis media with effusion
c. A defect in the 8th cranial nerve
d. A defect in the sensory fibres that lead to the cerebral cortex
e. A physical obstruction to the transmission of sound waves
101. While collecting data related to the cardiac system on a client, the nurse hears a murmur.
Which best describes the sound of a heart murmur?
a. Lub-dub sounds
b. Scratchy, leathery heart noise
c. Gentle, blowing or swooshing noise
d. Abrupt, high pitched snapping noise

102. The nurse is preparing to assist the health care provider to test the extraocular movements in a
client and muscle weakness in the eyes. The nurse anticipates which physical assessment technique
will be done?
a. Testing using the ishihara chart
b. Testing using a snellen eye chart
c. Testing the corneal light reflexes
d. Testing the six cardinal positions of gaze

103. The nurse is reinforcing instructions for a client in how to perform a testicular self-
examination (TSE). Which instructions should the nurse include? Select all that apply.
a. Perform TSE after a shower or bath
b. Perform TSE after emptying the bladder
c. Perform TSE on the same day each month
d. Observe for urethral discharge after performing TSE
e. Perform TSE by rolling each testicle between thumb and fingers

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104. The nurse notes the physical assessment findings for a client with a diagnosis of possible
meningitis. Which findings should the nurse expect to observe because of meningeal irritation?
Select all that apply.
a. Pupils are unequal and react slowly to light
b. The client reports stiffness and soreness in the neck area
c. The client reports pain in the vertebral column and passively flexes the hip and knee in
response to neck flexion
d. The client flexes a leg at the hip and knee and reports pain in the vertebral column when the
leg is extended
e. The client’s upper arms are flexed and held tightly to the sides of the body, and the legs are
extended and internally rotated

105. A spanish-speaking client arrives at the triage desk in the ED and states to the nurse “no
speak english, need interpreter”. Which action should the nurse take?
a. Have one of the client’s family members interpret
b. Have the spanish-speaking triage receptionist interpret
c. Seek an interpreter from the hospitals interpreter services
d. Obtain a spanish-english dictionary and attempt to triage the client

106. A mother calls a neighbourhood nurse and tells the nurse that her 3 year old child has just
ingested liquid furniture polish. Which action should the nurse instruct the mother to take first?
a. Induce vomiting
b. Call an ambulance
c. Call the poison control center
d. Bring the child to the ED

107. The ED nurse receives a telephone call and is informed that a tornado has hit a local
residential area and numerous casualties have occurred. The victims will be brought to the ED.
Which should be the initial nursing action?
a. Prepare the triage rooms
b. Activate the agency emergency response plan
c. Obtain additional supplies from the central supply department
d. Obtain additional nursing staff to assist with treating the casualties

108. The nurse is caring for a client with a health care associated infection caused by methicillin-
resistant staphylococcus aureus. Contact precautions are prescribed for the client. The nurse prepares
to irrigate the wound and apply a new dressing. Which protective interventions should the nurse use
to perform this procedure? Select all that apply
a. Put on a mask
b. Don gown and gloves
c. Apply shoe protectors
d. Wear a pair of protective goggles
e. Have the client wear a mask and goggles

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109. The nurse should institute which interventions for a client diagnosed with clostridium
difficile? Select all that apply
a. Wear a mask if within 3 feet of the client
b. Place a mask on the client when the client is outside of the room
c. Wear gloves and gown while in the room caring for the client
d. Use soap and water, not alcohol based hand rub, for hand hygiene
e. Keep the door of the room shut except when entering or exiting the client room

110. The nurse enters a client’s room and finds that the wastebasket is on fire. The nurse quickly
assists the client out of the room. Which is the next nursing action?
a. Call for help
b. Extinguish the fire
c. Activate the fire alarm
d. Confine the fire by closing the room door

111. A LPN attends a session about bioterrorism agents including anthrax. Which statement by an
attendee demonstrates the need for further teaching about anthrax?
a. Anthrax is treated with antibiotic medications
b. The most lethal form of anthrax is contacted by inhalation of the spores
c. Anthrax can be transmitted by consumption of meat from an infected animal
d. Anthrax bacteria produces a neurotoxin leading to a serious, possibly fatal paralysis

112. The nurse obtains a prescription to restrain a client using a belt (safety) restraint and instructs
the unlicensed assistive personnel to apply the restraint. Which observation, if made by the nurse,
indicates unsafe application of the restraint?
a. A safety knot is made in the restraint strap
b. The restraint straps are safely secured to the side rails
c. The restraint strap does not tighten when force is applied against it
d. The restraint is secure, and the client is able to turn from back to side

113. The nurse applies wrist restraints, prescribed to prevent a client from pulling out a nasogastric
tube. How should the nurse determine that the restraints are not too constrictive?
a. Observe the skin in the wrist area for redness
b. Check the temperature of the skin in the hands
c. Place two fingers under the restraint to determine the snugness
d. Remove the restraint and exercise the extremities in 2 hours

114. The nurse is assisting with planning care for a client with an internal radiation implant.
Which should be included in the plan of care? Select all that apply.
a. Wearing gloves when emptying the client’s bedpan
b. Keeping all linens in the room until the implant is removed
c. Wearing a film (dosimeter) badge when in the client’s room
d. Wearing a lead apron when providing direct care to the client
e. Placing the client in a semi private room at the end of the hallway

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115. The nurse enters the nursing lounge and discovers that a chair is on fire. The nurse activates
the alarm, closes the lounge door, and obtains the fire extinguisher to extinguish the fire. The nurse
pulls the pin on the fire extinguisher. Which is the next action the nurse should perform?
a. Aim at the base of the fire
b. Squeeze the handle of the extinguisher
c. Sweep the fire from side to side with the extinguisher
d. Sweep the fire from top to bottom with the extinguisher

116. The medication prescribed is hydromorphone hydrochloride 3mg intramuscularly, every 4

hours as needed. The medication label reads hydromorphone hydrochloride 4mg/1mL. The nurse
should prepare to administer how many mL to the client? Fill in the blank
_______________ mL

117. The medication prescribed is digoxin 0.25mg orally, daily. The medication label reads
digoxin 0.125 mg/tablet. The nurse should prepare to administer how many tablets to administer the
dose? Fill in the blank
_______________ tablet(s)

118. The medication prescribed is heparin 5000 units subcutaneously, every 12 hours. The
medication vial reads heparin 10,000 units/mL. The nurse prepares how many millilitres to
administer one dose? Fill in the blank
_______________ mL

119. The medication prescribed is metoclopramide hydrochloride 10 mg intramuscularly times one

dose. The medication label reads metoclopramide hydrochloride 5mg/mL. The nurse prepares how
much medication to administer the dose? Fill in the blank
_______________ mL

120. The medication prescribed is morphine sulfate 6 mg subcutaneously. The medication label
states morphine sulfate 10 mg/mL. The nurse plans to prepare how much medication to administer
the dose? Fill in the blank
_______________ mL
121. The medication prescribed is prochlorperazine 5 mg intramuscularly, every 4 hours as
needed. The medication label states prochlorperazine 10 mg/mL. The nurse prepares how much
medication to administer the dose? Fill in the blank
_______________ mL

122. The medication prescribed is haloperidol, 4 mg intramuscularly, immediately. The

medication label states 5 mg/1 mL. The nurse prepares how much medication to administer the dose?
Fill in the blank and round the answer to one decimal point
_______________ mL

123. The medication prescribed is levodopa 1g orally, daily. The medication label states levodopa
500 mg tablets. The nurse prepares to administer how many tablets at the evening dose? Fill in the
blank
_______________ tablets

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124. The medication prescribed is zidovudine, 0.2 g orally, 3 times daily. The medication label
states zidovudine, 100 mg tablets. The nurse prepares to administer how many tablets for one dose?
Fill in the blank
_______________ tablets

125. The medication prescribed is methylprednisolone acetate 60 mg intramuscularly. The

medication label states methylprednisolone acetate 40 mg/1 mL. How many mL will the nurse
prepare to administer to the client? Fill in the blank
_______________ mL

126. The medication prescription states to administer acetaminophen 650 mg orally for a
temperature of 38 C. The medication bottle states acetaminophen 325 mg tablets. The nurse takes the
client’s temperature and notes that it is 101 F. The nurse plans to take which action?
a. Administer two tablets
b. Administer 3 tablets
c. Do not administer at this time
d. Check the clients temperature in 30 minutes

127. The medication prescription reads phenytoin 0.2 g orally, twice daily. The medication label
states 100 mg capsules. The nurse prepares how many capsules to administer one dose? Fill in the
blank
_______________ capsules

128. The IV prescription is 1000 mL of 0.9 NS to run over 12 hours. The drop factor is 15 gtt/1
mL. The nurse plans to adjust the flow rate to how many gtts/minute? Fill in the blank and round to
the nearest whole number
_______________ gtts/minute

129. The medication is an intramuscular dose of 400,000 units of penicillin G benzathine. The
medication label reads penicillin G benzathine 300,000 units/mL. The nurse prepares how much
medication to administer the correct dose? Fill in the blank and record the answer using one decimal
place.
_______________ mL

130. The IV prescription is 3000 mL of 5% dextrose in water to run over a 24 hour period. The
drop factor is 10 gtts/mL. The nurse plans to adjust the flow rate to how many gtts/minute? Fill in the
blank and record the answer to the nearest whole number
_______________ gtts/minute

131. The nurse is developing a plan of care for a client who is scheduled for surgery. The nurse
should include which activities in the nursing care plan for the client on the day of surgery? Select all
that apply
a. Have the client void before surgery
b. Avoid oral hygiene and rinsing with mouthwash
c. Verify that the client has not eaten for the last 24 hours
d. Determine that the client has signed the informed consent for the surgical procedure

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 e. Report immediately any slight increase in blood pressure or pulse from the client’s baseline
vital signs

132. The nurse is caring for a client who is scheduled for surgery. The client states concern about
the surgical procedure. How should the nurse initially address the client's concerns?
a. Tell the client that preoperative fear is normal
b. Explain that all nursing care and possible discomfort that may result
c. Ask the client to discuss information known about the planned surgery
d. Provide explanations about the procedures involved in the planned surgery

133. The nurse is collecting data from a client who is scheduled for surgery in 1 week in the
ambulatory care surgical center. Which client data are pertinent and should be reported to the PHCP
before the surgery? Select all that apply
a. Is allergic to penicillin
b. Quit smoking 3 months earlier
c. History of tonsillectomy at the age of 7
d. Wonders if the surgery can cause incontinence
e. Takes daily multivitamin and calcium supplement
f. History of DVT in right leg 10 years earlier

134. The nurse obtains the vital signs on a postoperative client who just returned to the nursing
unit. The client’s blood pressure is 100/60, the pulse is 60 BPM, and the respiratory rate is 20 breaths
per minute. On the basis of these findings, which actions should the nurse take? Select all that apply
a. Ask if the client is thirsty and assist with drinking a glass of water
b. Ask how the client feels and inquire about any feelings of dizziness
c. Review the client record to determine time and type of analgesia last received
d. Review the client record to determine whether the client has voided postoperatively
e. Assist the client to perform leg exercises and then recheck the BP and pulse rate
f. Review the client record to note the vital signs taken in the PACU

135. A client arrives at the surgical nursing unit after surgery. What should be the initial nursing
action after surgery?
a. Assess the patency of the airway
b. Check tubes or drains for patency
c. Check dressing for bleeding or drainage
d. Obtain vital signs to compare with those recorded postoperatively

136. The nurse is monitoring an adult client for postoperative complications. Which is most
indicative of a potential postoperative complication that requires further observation?
a. A urinary output of 20 mL/hour
b. A temperature of 37.6 C (99.6 F)
c. A blood pressure of 100/70
d. Serous drainage on the surgical dressing

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137. The nurse monitors the 3 day postoperative client who underwent abdominal surgery. Vital
signs are: T 37.9 (100.2), Pulse 104, RR 22, BP 128/74, O2 93% room air. The client feels tired and
has a productive cough. Fine crackles are audible in the bases of the lungs posteriorly. The nurse
considers the client has developed which postoperative problem?
a. Hypoxia
b. Atelectasis
c. Pneumonia
d. Fluid overload

138. The nurse is caring for a postoperative client who has a jackson pratt drain inserted into the
surgical wound. What actions should the nurse take in care of the drain? Select all that apply.
a. Check the drain for patency
b. Check that the drain is decompressed
c. Observe for bright red, bloody drainage
d. Maintain aseptic technique when emptying
e. Empty the drain when it is half full and every 8-12 hours
f. Secure the drain by curling or folding it and taping it firmly to the body

139. The nurse checks the postoperative client for signs of infection. Which observations are
indicative of a potential infection? Select all that apply
a. Slight redness along the incision
b. The presence of purulent drainage
c. A temperature of 98.8 F (37.1 C)
d. The client states that he feels cold
e. The client states that the incision itches
f. Tender firmness palpable around the incision

140. The nurse is checking a client’s surgical incision and notes an increase in the amount of
drainage, a separation of the incision line, and the appearance of underlying tissue. Which actions
should the nurse take to deal with this event? Select all that apply
a. Turn the client to the side with the knees bent
b. Apply a sterile dressing soaked with NS to the wound
c. Notify the RN and PHCP at once
d. Explain to the client that obesity is a risk factor and weight loss should be a future goal
e. Gently explore the wound with a cotton tipped applicator to determine whether evisceration
has occurred

141. The nurse is preparing to reposition a dependent client who weighs more than 250 pounds.
Which interventions should the nurse use to move this client? Select all that apply
a. Use a friction-reducing slide sheet
b. Use a mechanical lift to move the client
c. Place the client in trendelenburg position
d. Keep elbows close and work close to the body
e. Administer oral pain medication 5 minutes before moving the client
f. Obtain assistance of a second caregiver to assist with medical aids

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142. The nurse is assigned to assist with caring for a client after cardiac catheterization performed
through the left femoral artery. The nurse should plan to maintain bed rest for this client in what
position
a. High fowler's position
b. Supine with no head elevation
c. Left lateral (side lying) position
d. Supine with head elevation no greater than 30 degrees

143. The nurse is reinforcing home care instructions to a client and family regarding care after left
cataract surgery with lens implant. Which statements made by the client indicate an understanding of
the instructions? Select all that apply
a. “I will bend over to tie my shoe laces”
b. “I will not sleep lying on my left side”
c. “I will sit at the table to eat my breakfast”
d. “I will sit in my recliner with my feet elevated”
e. “I will not lift anything heavier than 10 pounds”
f. “I will resume my exercise routine including pushups”

144. After a client undergoes a liver biopsy, the nurse places the client in the prescribed right side
lying position. The nurse understands that the purpose of this intervention is to accomplish which?
a. Promote bile flow
b. Limit client discomfort
c. Promote hepatic glucose storage
d. Limit bleeding from the biopsy site

145. The nurse is administering a cleansing enema to a client with a fecal impaction. Before
administering the enema, the nurse asks the client to assume a left sim’s position. The nurse explains
that this positioning is preferred because of which reason?
a. The nurse is right handed
b. The rectal sphincter will relax
c. The enema will flow into the bowel easily
d. The client is more likely to reliant the enema solution

146. A client is being prepared for a thoracentesis. The nurse reinforces instructions with the client
given by the RN. Which points should be included in the instructions? Select all that apply
a. The client leans over a bedside table
b. The client should sit on the edge of the bed
c. The procedure involves obtaining a biopsy
d. A time-out is performed before the procedure
e. The procedure is performed during a bronchoscopy
f. A local anesthetic is administered before the procedure

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147. The nurse is assisting with the insertion of an NG tube into a client. The nurse should place
the client in which position for insertion?
a. Right side
b. Low fowlers
c. High fowlers
d. Supine with the head flat

148. The nurse is assisting with caring for a client after a craniotomy. Which are the positions that
can be used for the client? Select all that apply.
a. Prone position
b. Supine position
c. Semi fowler's position
d. Dorsal recumbent position
e. With the foot of the bed flat
f. With the foot of the bed elevated 30 degrees

149. The nurse is caring for a client following a craniotomy in which a large tumor was removed
from the left side. In which position can the nurse safely place the client?
a. Head of the bed up
b. Trandelenburg
c. Entire bed elevated up
d. Bed flat

150. A client has just returned to a nursing unit after an above-knee amputation of the right leg.
The nurse should plan to place the client in which position
a. Prone
b. Reverse trendelenburg
c. Supine, with the residual limb flat on the bed
d. Supine, with the residual limb supported with pillows

151. The nurse is preparing to administer an intermittent tube feeding to a client. The nurse
aspirates 90 mL of residual from the tube. What should the nurse do? Select all that apply
a. Hold the feeding
b. Document the amount of residual
c. Place it into a container for laboratory analysis
d. Reinstill the residual and administer the feeding
e. Deduct the amount of residual from the new feeding before administering

152. The nurse is providing endotracheal suctioning to a client who is mechanically ventilated
when the client becomes restless and tachycardic. Which actions should the nurse take? Select all
that apply
a. Notify the RN
b. Notify the rapid response team
c. Finish suctioning as quickly as possible
d. Discontinue suctioning until the client is stabilized
e. Contact the respiratory department to suction the client

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153. The nurse has inserted an NG tube in a client and is checking for the correct placement of a
NG tube. Which is the most reliable data to ensure that the end of the tube is in the stomach?
a. Placement is verified on x-ray
b. The pH of the aspirated fluid is 5
c. The aspirated fluid is bile green in colour
d. Air injection is auscultated in the left upper quadrant

154. A LPN is preparing to assist the RN with removing a NG tube from the client. Which
interventions should be included in the procedure? Select all that apply
a. Remove the air from the balloon
b. Explain the procedure to the client
c. Ask the client to take a deep breath and hold
d. Pull the tube out in one continuously steady motion
e. Remove the device or tape securing the tube from the nose

155. The nurse is assisting with monitoring the functioning of a chest tube drainage system in a
client who just returned from the recovery room after a thoracotomy with wedge resection. Which
findings should the nurse expect to note? Select all that apply
a. Excessive bubbling in the water-seal chamber
b. Vigorous bubbling in the suction control chamber
c. 50 mL of drainage in the drainage collection chamber
d. The drainage system is maintained below the client’s chest
e. An occlusive dressing is in place over chest tube insertion site
f. Fluctuation of water in the tube of water seal chamber during inhalation and exhalation

156. The nurse is assigned to assist with caring for a client with esophageal varices who had a
sengstaken-blakemore tube inserted because other treatment measures were unsuccessful. The nurse
should check the client’s room to ensure that which priority item is at the bedside?
a. An obturator
b. A kelly clamp
c. An irrigation set
d. A pair of scissors

157. The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is
inserted into the urethra, urine begins to flow into the tubing. When should the nurse inflate the
balloon?
a. Immediately inflate the balloon
b. Insert the catheter 2.5-5cm and inflate the balloon
c. Advance the catheter to the bifurcation and inflate the balloon
d. Insert the catheter until resistance is met and inflate the balloon

158. The nurse is assigned to assist with caring for a client who has a chest tube. The nurse notes
fluctuations of the fluid level in the water-seal chamber. Based on this observation, which action
would be appropriate?
a. Continue to monitor
b. Empty the drainage
c. Encourage the client to deep breathe

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 d. Encourage the client to hold their breath periodically
159. The nurse is assigned to assist the PHCP with the removal of a chest tube. Which
interventions should the nurse anticipate performing during this process? Select all that apply
a. Reinforce instructions to breathe deeply while the tube is removed
b. Cover the site with an occlusive dressing after the tube is removed
c. Clamp the chest tube near the insertion site just before the removal
d. Raise the drainage system to the level of the chest tube insertion site
e. Have the client perform the valsalva maneuver as the chest tube is pulled out

160. The nurse is planning to begin a continuous tube feeding on a client with an NG tube. Which
interventions should the nurse perform before initiating the feeding? Select all that apply
a. Explain the procedure to the client
b. Irrigate the NG tube with NS
c. Aspirate all stomach contents and discard
d. Elevate the HOB 45 degrees
e. Have a pair of scissors for emergency use at the bedside
f. Ensure that the end of the NG tube is in the esophagus

161. The nurse is preparing to administer an intermittent tube feeding to a client with an NG tube.
The nurse checks the residual and obtains an amount of 200 mL. Which actions should the nurse
take? Select all that apply
a. Listen to the client’s bowel sounds
b. Document and discard the residual
c. Offer the client sips of water to drink
d. Question the client regarding nausea
e. Determine whether the client has abdominal distension
f. Hold the feeding after flushing the tube with 30 mL NS

162. The nurse is assisting in planning care for a client with a chest tube. The nurse should suggest
to include what interventions in the plan? Select all that apply
a. Pin the tubing to the bed linens
b. Be sure all connections remain airtight
c. Be sure all connections are taped and secure
d. Monitor closely for tubing that is kinked or obstructed
e. Empty the drainage from the drainage collection chamber daily

163. The nurse is assigned to care for a client who has a chest tube. The nurse is told to monitor
the client for crepitus (subcutaneous emphysema). Which method should be used to monitor the
client for crepitus?
a. Auscultating the posterior breath sounds
b. Asking the client about pain upon inspiration
c. Placing the hands over the rib area and observing expansion
d. Palpating the skin around the chest and neck for a cracking sensation

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164. The nurse is told that the assigned client will have a fenestrated tracheostomy tube inserted.
The nurse plans care knowing which facts are true with that of a fenestrated tracheostomy tube?
Select all that apply.
a. Enables the client to speak
b. Is necessary for mechanical ventilation
c. Must have the cuff deflated when capped
d. Eliminates the need for tracheostomy care
e. Prevents air from being inhaled through the tracheostomy opening

165. The nurse is preparing to administer a medication through a NG tube that is connected to
suction. Which interventions should be included to accurately administer the medication? Select all
that apply
a. Position the client supine to assist with medication absorption
b. Clamp the NG tube for 30 minutes after medication administration
c. Before medication administration, verify correct placement of the tube
d. Flush the NG tube with saline before and after medication administration
e. Discontinue the suction from the tube during administration of medication

166. Which statement by a nursing student about kohlberg's theory of moral development
indicates the need for further teaching about the theory?
a. “Individuals move through all 6 stages in a sequential fashion”
b. “Moral development progresses in relation to cognitive development”
c. “A person's ability to make moral judgements develops over a period of time”
d. “It provides a framework for understanding how individuals determine a moral code to guide
his or her behaviour”

167. The parents of an 8 year old child tell the nurse that they are concerned about the child
because the child seems to be more attentive to friends than anyone else. Which is the appropriate
nursing response?
a. “You need to be more concerned”
b. “You need to monitor the child’s behaviour closely”
c. “You need to praise the child more often to stop this behaviour”
d. “At this age, the child is developing his or her own personality”

168. The nurse notes that a 6 year old child does not recognize that objects exist even when the
objects are outside of the visual field. Based on this observation, which action should the nurse take?
a. Move the objects in the child’s direct field of vision
b. Teach the child how to visually scan the environment
c. Report the observation to the PHCP
d. Provide additional lighting for the child during play activities

169. The nurse is providing instructions to a new parent regarding the psychosocial development
of the infant. Using Erikson’s psychosocial development theory, which instruction should the nurse
reinforce to the parents?
a. Allow the infant to signal a need
b. Anticipate all of the needs of the infant
c. Attend to the crying infant immediately

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 d. Avoid the infant during the first 10 minutes of crying
170. The parent of a 3 year old tells the nurse that the child is constantly rebelling and having
temper tantrums. Which instruction should the nurse reinforce to the parent?
a. Set limits on the child’s behaviour
b. Ignore the child when this behaviour occurs
c. Allow the behaviour, because this is normal at this age period
d. Punish the child every time the child says “no” to change the behaviour

171. The nurse is caring for an older client who is reminiscing about past life experiences in a
positive manner. The nurse plans care with the understanding that this behaviour indicates which?
a. A mental status alteration
b. A normal psychosocial response
c. A need for psychiatric consultation
d. A sensory deficit requiring social activities

172. The nurse is observing a parent and child interacting in the clinic waiting room. The child
begins to bounce on the couch. The parent removes the child from the couch stating firmly “couches
are for sitting, not for jumping”. The parent then gives the child a toy to play with on the carpet. The
child plays with the toy until called by the nurse. The nurse determines the child is acting within
which Kohlberg stage of moral development?
a. Egocentric judgement
b. Law and order orientation
c. Punishment obedient stage
d. Good boy - nice girl orientation

173. The nurse determines a child is in the “preoperational” phase of Piaget's cognitive
developmental theory when the child makes which statement?
a. “I know all my multiplication tables my memory”
b. “The ball is gone” when the ball moves out of sight
c. “I’ll use a map to help me find my way in a new town”
d. “The moon follows me, and goes to bed when I go to bed”

174. A child remarks “I share my toys and snacks with my friends so they will like me more”. The
nurse determines the child is in which stage of moral development?
a. Egocentric judgement
b. Law and order orientation
c. Good boy - nice girl orientation
d. Social contract and legalistic orientation

175. The nursing student is preparing a conference on Freud’s psychosexual stages of

development, specifically the anal stage. Which appropriately relates to this stage?
a. Gratification of self
b. Beginning of toilet training
c. Tapering off of conscious biological and sexual urges
d. Association with pleasurable and conflicting feelings about the genital organs

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176. The parents of a 16 year old child tell the nurse that they are concerned because the child
sleeps until noon every weekend. Which is the most appropriate nursing response?
a. “Adolescents love to sleep late in the morning”
b. “The child shouldn’t be staying up so late at night”
c. “If the child eats properly, that shouldn't be happening”
d. “The child should have a blood test to check for anemia”

177. A 16 year old child is admitted to the hospital for acute appendicitis, and an appendectomy is
performed. Which intervention is most appropriate to facilitate normal growth and development?
a. Encourage the child to rest and read
b. Encourage the parents to room in with the child
c. Allow the family to bring in favourite computer games
d. Allow the child to participate in activities with other individuals in the same age group when
the condition permits

178. The nurse is reinforcing discharge instructions to the parents of a 2 year old child who
sustained accidental burns from a hot cup of coffee. The nurse determines that the parents have
correctly understood the teaching when they make which statement?
a. “We will be sure not to leave hot liquids unattended”
b. “I guess my child needs to understand what the word hot means”
c. “We will be sure that our child stays in his room while we work in the kitchen”
d. We will install a safety gate as soon as we get home so that our child can’t get into the
kitchen

179. Which interventions are appropriate for the care of an infant? Select all that apply
a. Provide swaddling
b. Talk in a loud voice
c. Provide the infant with a bottle of juice at naptime
d. Hang mobiles with black and white contrast designs
e. Caress the infant while bathing or during diaper changes
f. Allow the infant to cry for at least 10 minutes before responding

180. The nurse is preparing to care for a dying client and several family members are at the
client’s bedside. Which therapeutic techniques should the nurse use when communicating with the
family? Select all that apply
a. Discourage reminiscing
b. Make the decisions for the family
c. Encourage expressions of feelings, concerns and fears
d. Explain everything that is happening to all family members
e. Touch and hold the client’s or family member’s hands if appropriate
f. Be honest and let the client and family know that they will not be abandoned by the nurse

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181. The parents of a 2 year old arrive at the hospital to visit their child. The child is in the
playroom and ignores the parents during the visit. The nurse tells the parents that this behaviour in a
2 year old child indicates which characteristic about the child?
a. The child is withdrawn
b. The child is upset with the parents
c. The child is exhibiting a normal pattern
d. The child has adjusted to the hospitalized setting

182. When caring for a 3 year old child, the nurse should provide which toy for the child?
a. A puzzle
b. A wagon
c. A golf set
d. A miniature farm set

183. Upon palpation of the fontanel of a 3 month old newborn, the nurse notes that the anterior
fontanel has not closed and is soft and flat. Which action should the nurse take?
a. Increase oral fluid
b. Document the findings
c. Notify the RN
d. Elevate the head of the bed to 90 degrees

184. The nurse is caring for a 5 year old child who has been placed in traction after a fracture of
the femur. Which is the most appropriate activity for this child?
a. Blocks
b. A music video
c. A 10 piece puzzle
d. Large picture books

185. The parent of a 4 year old child expresses concern because her hospitalized child has started
sucking his thumb. The mother states that this behaviour began 2 days after hospital admission.
Which is the appropriate nursing response?
a. “Your child is acting like a baby”
b. “The doctor will need to be notified”
c. “This is common during hospitalization”
d. “A 4 year old is too old for this type of behaviour”

186. An older client has been prescribed digoxin. The nurse determines which age-related change
would place the client as risk for digoxin toxicity?
a. Decreased salivation and GI motility
b. Decreased muscle strength and loss of bone density
c. Decreased lean body mass and glomerular filtration rate
d. Decreased cardiac output and decreased efficiency of blood return to the heart

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187. The nurse should plan which to encourage autonomy in the client who is a resident in a LTC
facility?
a. Choosing meals
b. Decorating the room
c. Scheduling haircut appointments
d. Allowing the client to choose social activities

188. Which data indicate to the nurse that a client is experiencing effective coping following the
loss of a spouse? Select all that apply
a. Looks at old snapshots of family
b. Constantly neglects personal grooming
c. Visits the spouses grave once a month
d. Visits the senior citizens center once a month
e. Prefers to spend time alone and avoids contact with others

189. The nurse is preparing to communicate with an older client who is hearing impaired. Which
intervention should be implemented initially?
a. Stand in front of the client
b. Exaggerate lip movements
c. Obtain a sign language interpreter
d. Pantomime and write the client notes

190. Which intervention should be implemented for the older client with presbycusis who has
hearing loss?
a. Speak louder
b. Speak more slowly
c. Use low-pitched tones
d. Use high-pitched tones

191. When the nurse is collecting data from the older adult, which findings should be considered
normal physiological changes? Select all that apply
a. Increased heart rate
b. Decline in visual activity
c. Decreased respiratory rate
d. Decline in long term memory
e. Increased susceptibility to UTI’s
f. Increased incidence of awakening after sleep onset

192. The nurse is planning to feed an older client who is at risk for aspirating food. During the
meal, how should the nurse position the client?
a. Upright in a chair
b. On the left side in bed
c. On the right side in bed
d. In a low fowler's position, with the legs elevated

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193. The nurse is providing an education class to healthy older adults. Which exercise will best
promote health maintenance?
a. Gardening every day for an hour
b. Sculpting once a week for 40 minutes
c. Cycling three times a week for 20 minutes
d. Walking 3-5 times a week for 30 minutes

194. The nurse should implement which activity to promote reminiscence among older clients?
a. Having storytelling hours
b. Setting up pet therapy sessions
c. Displaying calendars and clocks
d. Encouraging client participation in a pottery class

195. Which client is most likely at risk to become a victim of elder abuse?
a. A 75 year old man with moderate HTN
b. A 68 year old man with newly diagnosed cataracts
c. A 90 year old woman with advanced alzheimers
d. A 70 year old woman with early diagnosed lyme disease

196. The nurse is collecting data from a pregnant client when the client asks the nurse about the
purpose of fallopian tubes. Which is the accurate response the nurse should make?
a. The organ of copulation
b. Where the fetus develops
c. Where fertilization occurs
d. The organ that secretes estrogen and progesterone

197. The nursing instructor asks a nursing student to list the functions of the amniotic fluid. The
student needs further teaching if what responses are made? Select all that apply.
a. Allows for fetal movement
b. Is a measure of kidney function
c. Surrounds, cushions and protects the fetus
d. Maintains body temperature of the fetus
e. Prevents large particles such as bacteria from passing to the fetus
f. Provides an exchange of nutrients and waste products between mother and fetus

198. The nurse working in a prenatal clinic reviews a client’s chart and notes that the PHCP
documents that the client has a gynecoid pelvis. The nurse plans care understanding that which
findings are characteristic of this type of pelvis? Select all that apply
a. Round shape
b. Shallow depth
c. Narrow pubic arch
d. Diagonal conjugate measures 12.5-13 cm
e. Blunt, somewhat widely separated ischial spines

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199. The client asks the nurse about the purpose of the placenta. The nurse plans to respond to the
client knowing which about the placenta?
a. Cushions and protects the fetus
b. Maintains body temperature of the fetus
c. Surrounds the fetus and allows for fetal movement
d. Provides an exchange of nutrients and waste products between mother and the fetus

200. The nurse is describing the process of fetal circulation to a client during a prenatal visit. The
nurse should tell the client that fetal circulation consists of which components?
a. Two umbilical veins and one umbilical artery
b. Two umbilical arteries and one umbilical vein
c. Arteries that carry oxygenated blood to the fetus
d. Veins that carry deoxygenated blood to the fetus

You’re finished Test #1!

See the answer sheet to check your work!
Keep studying hard!
We’re almost there!

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 Saunders Exam Practice Questions Test #2
201. A nursing student is assigned to a client in labor. The nursing instructor asks the student to
describe fetal circulation, specifically the ductus venosus. The instructor determines that the student
understands the structure of the ductus venosus if the student states which about the ductus venosus?
a. Connects the pulmonary artery to the aorta
b. Is an opening between the left and right atria
c. Connects the umbilical vein to the inferior vena cava
d. Connects the umbilical artery to the inferior vena cava

202. During a prenatal visit, the nurse checks the fetal heart rate (FHR) of a client in the third
trimester of pregnancy. The nurse determines that the FHR is normal if which heart rate is noted?
a. 80 BPM
b. 100 BPM
c. 150 BPM
d. 180 BPM

203. The nurse is reinforcing teaching to a pregnant woman about the physiological effects and
hormonal changes that occur during pregnancy. The woman asks the nurse about the purpose of
estrogen. The nurse bases the response on which purpose of estrogen?
a. It maintains the uterine lining for implantation
b. It stimulates the metabolism of glucose and converts glucose to fat
c. It stimulates uterine development to provide an environment for the fetus and stimulates the
breasts to prepare for lactation
d. It prevents the involution of the corpus luteum and maintains the production of progesterone
until the placenta is formed

204. The nursing student is asked to describe the size of the uterus in a nonpregnant client. Which
response indicates an understanding of the anatomy of this structure
a. “The uterus weighs about 2 ounces”
b. “The uterus weighs about 2.2 pounds”
c. “The uterus has a capacity of about 50 mL”
d. “The uterus is round in shape and weighs approximately 1000 g”

205. A couple comes to the family planning clinic and asks about sterilization procedures. Which
question by the nurse helps determine whether this method of family planning is appropriate?
a. “Have either of you had surgery?”
b. “Do you plan to have other children”
c. “Do either of you have diabetes mellitus?”
d. “Do either of you have problems with high blood pressure?”

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206. The client arrives at the prenatal clinic for her first prenatal assessment. The client tells the
nurse that her first day of her last menstrual period (LMP) was October 20, 2019. Using Nägele’s
rule, the nurse determines that the estimated date of birth is which date?
a. July 12, 2020
b. July 27, 2020
c. August 12, 2020
d. August 27, 2020

207. A pregnant client asks the nurse in the clinic when she will be able to start feeling the fetus
move. The nurse responds by telling the mother that the fetal movements will be united between
which weeks of gestation?
a. 6 and 8 weeks
b. 8 and 10 weeks
c. 10 and 12 weeks
d. 16 and 20 weeks

208. The nurse is collecting data from a client who is pregnant with twins. The client has a healthy
5 year old child who was delivered at 38 weeks, and she tells the nurse that she does not have a
history of any type of abortion or fetal demise. The nurse should document which as the GTPAL for
this client?
a. G = 3, T = 2, P = 0, A = 0, L = 1
b. G = 2, T = 1, P = 0, A = 0, L = 1
c. G = 1, T = 1, P = 1, A = 0, L = 1
d. G = 2, T = 0, P = 0, A = 0, L = 1

209. The nurse is collecting data from a client who is pregnant with triplets. The client also has a 3
year old child who was born at 39 weeks gestation. The nurse should document which gravida and
para status on this client?
a. Gravida I, Para I
b. Gravida II, Para I
c. Gravida II, Para II
d. Gravida III, Para II

210. The nurse is reviewing the record of a client who has just been told that her pregnancy test is
positive. The nurse notes that the HCP has documented the presence of Goodell’s sign. The nurse
determines that this sign is the indicative of which change that occurs during pregnancy?
a. A softening of the cervix
b. The presence of fetal movement
c. The presence of human chorionic gonadotropin in the urine
d. A soft blowing sound that corresponds with the maternal pulse that is heard while
auscultating the uterus

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211. A primipara is being evaluated in the clinic during her second trimester of pregnancy. Which
occurrence indicates an abnormal physical finding that necessitates further testing?
a. Quickening
b. Braxton hicks contractions
c. Consistent increase in fundal height
d. FHR of 180 BPM

212. The nurse is collecting data from a pregnant client who is currently at 28 weeks gestation. At
her prior prenatal visit, her fundal height measured 22 cm. The nurse measures the fundal height at
this visit in cm and should expect which finding?
a. 22 cm
b. 26 cm
c. 32 cm
d. 40 cm

213. A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells
the nurse that she is experiencing irregular contractions. The nurse determines that the client is
experiencing Braxton Hicks contractions. Based on this finding, which nursing action is appropriate?
a. Contact the HCP
b. Instruct the client to maintain bed rest for the remainder of the pregnancy
c. Tell the client that these are common and may occur throughout the pregnancy
d. Call the maternity unit and inform them that the client will be admitted in a pre-labour
condition

214. The nurse is checking a client’s record for probable signs of pregnancy. Which are the
probable signs of pregnancy that the nurse should note? Select all that apply
a. Ballottement
b. Chadwick’s sign
c. Uterine enlargement
d. Braxton Hicks contractions
e. Outline of fetus via radiography ultrasound
f. FHR detected by nonelectric device

215. The nursing instructor asks a nursing student to describe the process of quickening. Which
statement indicates an understanding of this term?
a. “It is the fetal movement that is felt by the mother”
b. “It is the compressibility of the lower uterine segment”
c. “It is the irregular, painless contractions that occur throughout the pregnancy”
d. “It is the soft blowing sound that can be heard when the uterus is auscultated”

216. The client is undergoing an amniocentesis at 16 weeks gestation to detect the presence of
biochemical or chromosomal abnormalities. Which instructions should the nurse reinforce to the
client?
a. The bladder must be full during the examination
b. The bladder must be empty during the examination
c. She should not eat or drink anything 4-6 hours before the examination
d. She will be given Rho (D) immune globulin because she is Rh positive

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217. The client at 28 weeks gestation is Rh negative and Coombs antibody negative. The nurse
determines that the client understands what the nurse has taught her about Rh sensitization when the
client makes which statement?
a. “I know i can never have another child”
b. “I am glad I won’t ever have to have these shots if I have another child”
c. “I will have to have the injection once a month until the baby is born”
d. “I will tell the nurse at the hospital that I had an Rh shot during pregnancy”

218. While assisting with the measurement of fundal height, the client at 36 weeks gestation states
that she is feeling lightheaded. On the basis of the nurse’s knowledge of pregnancy, the nurse
determines that this is most likely a result of which reason?
a. A full bladder
b. Emotional instability
c. Insufficient iron intake
d. Compression of the vena cava

219. A contraction stress test is scheduled for the client. The woman asks the nurse about the test.
Which response describes the most accurate description of the test?
a. “Uterine contractions are stimulated by Leopold’s maneuvers”
b. “The uterus is stimulated to contract by either small amounts of oxytocin or by nipple
stimulation”
c. “An internal fetal monitor is attached, and you will walk on a treadmill until contractions
begin”
d. “Small amounts of oxytocin are administered during internal fetal monitoring to stimulate
uterine contractions”

220. The nurse is talking to a pregnant client with HIV regarding care for their newborn after
delivery. The client asks the nurse about the feeding options that are available. Which response
should the nurse make to the client?
a. “You will need to bottle feed your newborn”
b. “You will need to feed your newborn by NG tube feeding”
c. “You will be able to breastfeed for 6 months and then will need to switch to bottle feeding”
d. “You will be able to breastfeed for 9 months and then will need to switch to bottle feeding”

221. The perinatal client is admitted to the OB unit during an exacerbation of a heart condition.
When planning for the nutritional requirements of the client, the nurse should consult with the
dietitian to ensure what dietary measure?
a. A low calorie diet to ensure the absence of weight gain
b. A diet that is high in fluids and fibre to decrease constipation
c. A diet that is low in fluids and fibre to decrease the blood volume
d. Unlimited sodium intake to increase the circulating blood volume

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222. The nurse is caring for a client with abruptio placentae and is monitoring the client for signs
of disseminated intravascular coagulopathy (DIC). the nurse should suspect DIC if which is
observed?
a. Rapid clotting times
b. Pain and swelling of the calf of one leg
c. Laboratory values that indicate increased platelets
d. Petechiae, oozing from injection sites, and hematuria

223. The nurse has a teaching session with a malnourished client regarding iron supplementation
to prevent anemia during pregnancy. Which statement indicates successful learning?
a. “Iron supplements will give me diarrhea”
b. “The iron is needed for the RBC”
c. “Meat does not provide iron and should be avoided”
d. “My body has all the iron it needs and I don’t need to take supplements”

224. During a prenatal visit, the nurse is explaining dietary management to a client with DM. The
nurse determines that the teaching has been effective when the client makes what statement?
a. “I can eat more sweets now because I need more calories”
b. “I need more fat in my diet so that the baby can gain enough weight”
c. “I need to eat a high-protein, low carbohydrate diet now to control my blood glucose”
d. “I need to increase the fibre in my diet to control my blood glucose and prevent constipation”

225. The nurse is assigned to assist with caring for a client who is at risk for eclampsia. If the
client progresses from preeclampsia to eclampsia, the nurse should take which action first?
a. Administer oxygen by face mask
b. Clear and maintain an open airway
c. Check the blood pressure and the fetal heart tones
d. Prepare for the administration of IV magnesium sulfate

226. The client is in her second trimester of pregnancy. She complains of frequent low back pain
and ankle edema at the end of the day. The nurse should recommend which measure to help relieve
both discomforts?
a. Lie on the left side with the foot dorsiflexed
b. Soak the feet in hot water after performing 10 pelvic tilt exercises
c. Lie on the right side with the feet elevated on a pillow and a heating pad on the back
d. Lie on the floor with the legs elevated onto a couch or padded chair, with the hips and knees
at a right angle

227. The pregnant woman complains of being awakened frequently by leg cramps. The nurse
reinforces instructions to the client’s partner and should tell the client to perform which measure?
a. Dorsiflex the client’s foot while flexing the knee
b. Plantarflex the client’s foot while flexing the knee
c. Dorsiflex the client’s foot while extending the knee
d. Plantarflex the client’s foot while extending the knee

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228. The nurse is reinforcing instructions to a pregnant client regarding measures to prevent
heartburn. The nurse should instruct the client to take which best measure?
a. Eliminate between meal snacks
b. Drink decaffeinated coffee and tea
c. Lie down for 30 minutes after eating
d. Substitute salt in cooking for other spices

229. The nurse is monitoring a client with mild gestational hypertension (GH). Which data
indicate that GH is a concern?
a. Urinary output has increased
b. There is no evidence of proteinuria
c. The client complains of headache and blurred vision
d. The blood pressure reading has returned to the prenatal baseline

230. The nurse is monitoring a pregnant client with GH who is at risk for preeclampsia. The nurse
should check the client for which signs of preeclampsia? Select all that apply
a. Proteinuria
b. HTN
c. Low grade fever
d. Increased pulse rate
e. Increased respiratory rate

231. The nurse is assigned to care for a client who is in early labor. When collecting data from the
client, which should the nurse check first?
a. Baseline FHR
b. Intensity of contractions
c. Maternal blood pressure
d. Frequency of contractions

232. Leopold’s maneuvers will be performed on a pregnant client. The client asks the nurse about
the procedure. Which information should the nurse provide to the client about Leopold’s maneuvers?
a. The maneuvers measure the height of the maternal fundus
b. The maneuvers determine the “lie” and “attitude” of the fetus
c. The maneuvers are a systematic method for palpating the fetus through the maternal back
d. The maneuvers are a systematic method for palpating the fetus through the maternal
abdominal wall

233. The nurse is caring for a client who is in labour. The nurse rechecks the client’s blood
pressure and notes that it has dropped. To decrease the incidence of supine hypotension, the nurse
should encourage the client to remain in which position?
a. Squatting
b. Side - lying
c. Tailor sitting
d. Semi-fowlers

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234. After a precipitous delivery, the nurse notes that the new mother is passive and only touches
her newborn briefly with her fingertips. The nurse should do which to help the woman process what
has happened?
a. Support the mother in her reaction to the newborn
b. Encourage the mother to breastfeed soon after birth
c. Tell the mother that it is important to hold the newborn
d. Document a complete account of the mothers reaction in the birth record

235. A primigravida’s membranes rupture spontaneously. Which action should the nurse take
first?
a. Determine the FHR
b. Prepare for immediate delivery
c. Monitor the contraction pattern
d. Note the amount, colour, and odor of the amniotic fluid

236. Which findings indicate to the nurse that the placental separation has occurred? Select all that
apply.
a. Lengthening of the umbilical cord
b. Sudden trickle or spurt of blood
c. Fundus is boggy following separation
d. Change from globular to discoid shape
e. Fetal membranes are seen at the introitus

237. The nurse is assigned to assist with caring for a client who has been admitted to the labour
unit. The client is 9 cm dilated and is experiencing precipitous labour. Which is the priority nursing
action?
a. Prepare for oxytocin infusion
b. Keep the client in a side lying position
c. Prepare the client for epidural anesthesia
d. Encourage the client to start pushing with the contractions

238. The client is admitted to the labour suite complaining of painless vaginal bleeding. The nurse
assists with examination of the client, knowing that which routine labour procedure is
contraindicated?
a. Leopold's maneuvers
b. A manual pelvic examination
c. Hemoglobin and hematocrit evaluation
d. External electronic FHR monitoring

239. The nurse is assigned to assist with caring for a client with abruptio placentae who is
experiencing vaginal bleeding. The nurse collects data from the client, knowing that abruptio
placentae is accompanied by which additional finding?
a. Soft abdomen on palpation
b. Uterine tenderness on palpation
c. No complaints of abdominal pain
d. Lack of uterine irritability or tetanic contractions

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240. The nurse is collecting data from a client who has been diagnosed with placenta previa.
Which findings should the nurse expect to note? Select all that apply.
a. Uterine rigidity
b. Uterine tenderness
c. Severe abdominal pain
d. Bright red vaginal bleeding
e. Soft, relaxed, nontender uterus

241. The nurse is assisting with caring for a client with abruptio placentae. While caring for the
client, the nurse notes that the client begins to develop signs of shock. The nurse should take which
action first?
a. Monitor the urinary output
b. Monitor the maternal pulse
c. Turn the client onto her side
d. Monitor the maternal blood pressure

242. The client who is being prepared for a cesarean delivery is brought to the delivery room. To
maintain the optimal perfusion of oxygenated blood to the fetus, the nurse should place the client in
which position?
a. Prone position
b. Semi-fowlers position
c. Trandelenberg’s position
d. Supine position with a wedge under the right hip

243. A woman in active labour has contractions every 2-3 minutes that last for 45 seconds. The
FHR between contractions is 100 BPM. On the basis of these findings which is the priority nursing
action?
a. Monitor maternal vital signs
b. Notify the RN immediately
c. Continue monitoring labour and the FHR
d. Encourage relaxation and breathing techniques between contractions

244. The nurse is assigned to assist with caring for a client who is being admitted to the birthing
center in early labour. During admission, which action should the nurse take initially?
a. Estimate the fetal size
b. Check pelvic adequacy
c. Administer an analgesic
d. Determine the maternal and fetal vital signs

245. The nurse is assigned to work in the delivery room and is assisting with caring for a client
who has just delivered a newborn. The nurse is monitoring for signs of placental separation knowing
which indicates that the placenta has separated?
a. A change in the uterine contour
b. Sudden and sharp abdominal pain
c. A shortening of the umbilical cord
d. A decrease in blood loss from the introitus

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246. A client received epidural anesthesia during labor and had a forceps delivery after pushing for
2 hours. At 6 hours postpartum, the client’s systolic BP dropped 20 points, the diastolic BP dropped
10 points and her pulse is 120 BPM. The client is very anxious and restless. The nurse is told that the
client has a vulvar hematoma. Based on this diagnosis, the nurse should plan which action?
a. Reassure the client
b. Apply perineal pressure
c. Monitor the fundal height
d. Prepare the client for surgery

247. The nurse is preparing a list of self-care instructions for a postpartum client who has been
diagnosed with mastitis. Which instruction should be included on the list? Select all that apply
a. Rest during the acute phase
b. Where is supportive, non underwire bra
c. Maintain a fluid intake of at least 3,000 mL
d. Continue to breastfeed if the breasts are not too sore
e. Take prescribed antibiotics until the soreness subsides
f. Avoid decompression of the breast by breastfeeding or breast pumping.

248. A postpartum client is getting ready for discharge. The nurse suspects the client needs further
teaching related to breastfeeding when she makes which statement?
a. “I don't need birth control because I will be breastfeeding”
b. “I need to increase my caloric intake by 500 calories a day”
c. “I shouldn't use soap to wash my breasts because I will be breastfeeding”
d. “I need to be sure that I increase my fluid intake and take my prenatal vitamins while
breastfeeding”

249. The nurse is caring for a postpartum client with a diagnosis of thrombophlebitis. The client
suddenly complains of chest pain and dyspnea. The nurse should initially check which item?
a. Vital signs
b. Fundal height
c. Presence the calf pain
d. Level of consciousness

250. The nurse suspects that the client has a pulmonary embolism. Which is the most important
nursing action?
a. Monitor the vital signs
b. Elevate the head of the bed
c. Increase the intravenous flow rate
d. Administer Oxygen by face mask, as prescribed

251. The nurse notes that the 4-Hour postpartum client has cool, clammy skin and that she is
restless and excessively thirsty. The nurse immediately notifies the registered nurse and then
performs which action?
a. Check the vital signs
b. Begin fundal massage

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 c. Encourage ambulation
d. Encourage the client to drink fluids
252. The nurse is assisting with caring for a postpartum client who is experiencing uterine
Hemorrhage. When planning to meet the psychosocial needs of the client, the nurse should plan
which action?
a. Maintain strict bed rest.
b. Monitor the vital signs every 2 hours
c. Perform firm fundal massage every 2 hours
d. Keep the client in her family members informed of her progress

253. The nurse palpates the fundus and checks the character of the lochia of a postpartum client
who is in the fourth stage of Labor. Which lochia characteristics should the nurse expect to note?
a. Red
b. Pink
c. White
d. Serousosinguanous

254. After episiotomy and the delivery of a newborn, the nurse performs a perineal check on the
mother. The nurse notes a trickle of bright red blood coming from the perineum. The nurse checks
the fundus and notes that it is firm. Which determination should the nurse make?
a. This is a normal expectation after episiotomy
b. The mother should be allowed bathroom privileges only
c. The bright red bleeding is abnormal and should be reported
d. The perineal assessment should be performed more frequently

255. The nurse is assigned to care for the client during the postpartum period. The client asks the
nurse what the term involution means. Which description should the nurse give to the client?
a. The inverted uterus returning to normal
b. The gradual reversal of the uterine muscle into the abdominal cavity
c. The Descent of the uterus into the pelvic cavity, which occurs at a rate of 2 centimetres per
day
d. The progressive Descent of the uterus into the pelvic cavity, which occurs at a rate of
approximately 1 centimetre per day

256. A mother is breastfeeding her newborn baby and experiences breast engorgement. The nurse
should encourage the mother to do which to provide relief of engorgement?
a. Breastfeed only during daytime hours
b. Apply cold compresses to the breath before feeding
c. Avoid these for brawlhalla breasts are engorged
d. Massage the breast before feeding to stimulate let-down

257. After delivery the nurse checks the height of the uterine fundus. Which position of the
fundus should the nurse expect to note?
a. To the right of the abdomen
b. At the level of the umbilicus
c. About four centimetres above the level of the umbilicus
d. One finger breadth above the symphysis pubis

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258. The nurse is caring for a postpartum client. At 4 hours postpartum, the clients temperature is
102 F (38.9 C). Which is the appropriate nursing action?
a. Apply cool packs to the abdomen
b. Continue to monitor the temperature
c. Remove the blanket from the client's bed
d. Notify the registered nurse, who will then contact the primary health care provider

259. The nurse is assisting with planning care for a postpartum woman who has small vulvar
hematomas. To assist with reducing the swelling, the nurse should perform which action?
a. Check Vital Signs every 4 hours
b. Measure the fundal height every 4 hours
c. Prepare a heat pack for application to the area
d. Prepare an ice pack for application to the area

260. The nurse is assigned to care for the client after a cesarean section. To prevent
thrombophlebitis, the nurse should encourage the woman to take which priority action?
a. Ambulate frequently
b. Wear support stockings
c. Apply warm, moist packs to the legs
d. Remain on bed rest, with the legs elevated

261. The nurse administers erythromycin ointment (0.5%) to the newborn’s eyes and the mother
asks the nurse why this is done. The nurse should give which response to the client?
a. Prevent cataracts in the neonate born to a woman who susceptible to rubella
b. Protecting unit size from possible infections acquired while hospitalized
c. Minimalize is the spread of microorganisms to the neonate from invasive procedures during
labour
d. Prevents ophthalmia neonatorum from occurring after delivery to a neonate born to a woman
with an untreated gonococcal infection

262. A client asks the nurse why her newborn baby needs an injection of vitamin K. The nurse
should make which statement to the client?
a. “Your newborn needs vitamin K to develop immunity”
b. “The vitamin K will protect your newborn from becoming jaundiced”
c. “Newborns are deficient in vitamin K. This is injection prevent your baby from abnormal
bleeding”
d. “Newborns have sterile bowels. The vitamin K will give the bowel the necessary bacteria”

263. The nurse is assigned to assist with caring for a neonate born to a mother who is HIV-
positive. The nurse understands which should be included in the plan of care?
a. Monitoring the neonates Vital Signs routinely
b. Maintaining standard precautions at all times while caring for the neonate
c. Instructing breastfeeding mothers regarding the treatment of their nipples with an antifungal
cream

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 d. Initiating referral to evaluate for blindness, deafness, learning, or behavioral problems in the
neonate.
264. The nurse in the newborn Nursery receives a telephone call to prepare for the admission of a
neonate born at 43 weeks gestation with apgar scores of 1 and 4. When planning for the admission of
this infant, which is the nurse’s highest priority?
a. Turning on the apnea and cardiorespiratory monitor
b. Connecting a resuscitation bag to the oxygen Outlet
c. Setting up the intravenous line with 5% dextrose in water
d. Setting a radiant warmer control temperature at 36.5 C (97.6 F).

265. The nurse is assisting in caring for a post-term neonate immediately after admission to the
nursery. The priority nursing action should be to monitor which clinical parameter?
a. Urinary output
b. Blood glucose level
c. Total bilirubin level
d. Hemoglobin and hematocrit levels

266. The nurse is reinforcing instructions to a new mother about cord care and how to monitor for
the presence of an infection. The nurse should tell the mother that which is a sign of infection?
a. A darkened drying stump
b. A moist cord with discharge
c. A purple stump that shows pinkness around the base
d. A purple stop that shows some moistness around the base

267. The nurse is reinforcing measures regarding the care of a newborn with a mother. To bathe
the newborn, the mother should be taught which intervention?
a. Begin with the eyes and face
b. Start with the dirtiest area first
c. Begin with the feet and work upward
d. Only watch the diaper area, because this is the only part of the baby that gets soiled

268. After birth the nurse prevents hypothermia as a result of evaporation by performing which
action?
a. Warm in the crib pad
b. Closing the doors of the room
c. Drying the baby with a warm blanket
d. Turning on the overhead radiant warmer
269. The nurse is preparing to care for a newborn who is receiving phototherapy. Which measures
should be implemented? Select all that apply
a. Avoid stimulation
b. Decrease fluid intake
c. Expose all of the newborn’s skin
d. Monitor the skin temperature closely
e. Reposition a newborn every 2 hours
f. Cover the newborn's eyes with shield’s or patches

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270. A newborn has just been circumcised and is being discharged home in 2 hours. Which
instruction should be provided by the nurse to the parents? Select all that apply
a. Use only baby wipes to cleanse the penis
b. Remove the yellow exudate which forms by 24 hours post circumcision
c. Do not wash penis with soap until the circumcision is healed, which takes 5 to 6 days
d. Change diaper every 4 hours or more often to inspect the penis for drainage or infection
e. Monitor the circumcision, penis may appear reddened with a small amount of bloody
drainage shortly after the procedure

271. The nurse should monitor for which signs associated with respiratory distress syndrome in a
preterm newborn?
a. Tachypnea and retractions
b. Acrocyanosis and grunting
c. Hypotension and bradycardia
d. The presence of barrel chest with acrocyanosis

272. The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn after
admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which
additional sign is consistent with FAS?
a. A length of 19 inches
b. Abnormal palmar creases
c. A birth weight of 6 pounds, 14 oz
d. A head circumference is appropriate for gestational age

273. A pregnant hiv-positive woman delivers a baby. The nurse provides guidance to help the
client make decisions regarding newborn care. Which statement by the woman indicates that
additional guidance is needed?
a. “I will be sure to wash my hands before feeding the newborn”
b. “I will breastfeed, especially for the first 6 weeks postpartum”
c. “I'll be sure to wash my hands before and after bathroom use”
d. “I will administer the prescribed antiviral medication to the newborn for the first 6 weeks
after delivery”
274. A pregnant woman has a positive history of genital herpes, but she has not had lesions during
her pregnancy. The nurse plans to provide which information to the client?
a. “You'll be isolated from your newborn after delivery”
b. “There's little risk to your baby during your pregnancy, birth, and after delivery”
c. “Vaginal deliveries can reduce neonatal infection risk, even if you have an active lesion at
birth”
d. “You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are
present, a cesarean delivery will be needed”.

275. The nurse is planning to reinforce instructions about cord care to a new mother. The nurse
should plan to tell the mother which about cord care?
a. Alcohol is the only agent used to clean the cord
b. It takes 21 days for the cord to dry up and fall off
c. Cord care has done only at birth to control bleeding

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 d. The process of keeping the cord clean and dry will decrease bacterial growth
276. The nurse is monitoring a client who is receiving oxytocin to induce labour. Which
assessment findings should cause the nurse to immediately discontinue the oxytocin infusion? Select
all that apply
a. Fatigue
b. Drowsiness
c. Uterine hyperstimulation
d. Late decelerations of the fetal heart rate
e. Early decelerations of the fetal heart rate

277. A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The
nurse determines that the client is experiencing toxicity from the medication if which findings are
noted during the assessment? Select all that apply
a. Proteinuria of 3 +
b. Respirations of 10 breaths per minute
c. Presence of deep tendon reflexes
d. Urine output of 20 ml in 1 hour
e. Serum magnesium level of 6 mEq/L

278. The nurse is monitoring a client in preterm labour who is receiving intravenous magnesium
sulphate. The nurse should monitor for which adverse effects of this medication? Select all that apply
a. Flushing
b. Hypertension
c. Increase urine output
d. Depressed respirations
e. Extreme muscle weakness
f. Hyperactive deep tendon reflexes

279. The nursing instructor asks a student to describe the procedure for administering
erythromycin ointment to the eyes of a newborn. Which statement indicates that further teaching is
needed?
a. “I will flush the eyes after instilling the ointment”
b. “I will clean the newborn's eyes before instilling ointment”
c. “I need to administer the ointment within 1 hour after delivery”
d. “I will instill the eye ointment into each of the newborns conjunctival sac”

280. A client in preterm labour (31 weeks) who is dilated to 4 centimetres has been started on
magnesium sulphate and her contractions have stopped. If the clients labour can be inhibited for the
next 48 hours, the nurse anticipates a prescription for which medication?
a. Nalbuphine
b. Betamethasone
c. Rho immune globulin
d. Dinoprostone vaginal insert

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281. Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before
administration of Methylergonovine, what is the priority nursing assessment?
a. Uterine tone
b. Blood pressure
c. Amount of lochia
d. Deep tendon reflexes

282. The nurse is preparing to administer beractant to a premature infant who has respiratory
distress syndrome. The nurse plans to administer the medication by which route?
a. Intradermal
b. Intratracheal
c. Subcutaneous
d. Intramuscular

283. An opioid analgesic is administered to a client in labour. The nurse assigned to care for the
client ensures which medication is readily available if respiratory depression occurs?
a. Naloxone
b. Morphine sulphate
c. Betamethasone
d. Meperidine hydrochloride

284. Rho immune globulin is prescribed for a client after delivery and the nurse provides
information to the client about the purpose of the medication. The nurse determines that the woman
understands the purpose if the woman states that it will protect her next baby from which condition?
a. Having RH positive blood
b. Developing a rubella infection
c. Developing physiological jaundice
d. Being affected by RH incompatibility

285. Methylergonovine is provided for a client with postpartum hemorrhage. Before administering
the medication, the nurse contacts the primary health care provider who prescribed the medication if
which condition is documented in the client's medical history?
a. Hypotension
b. Hypothyroidism
c. Diabetes mellitus
d. Peripheral vascular disease

286. The school nurse prepares a list of home care instructions for the parents of school children
who've been diagnosed with pediculosis capitis (Head Lice). Which should be included on the list?
Select all that apply
a. Siblings may also need treatment
b. Use anti lice sprays on all bedding and furniture
c. Use a pediculicide shampoo and repeat treatment in 14 days
d. Grooming items such as Combs and brushes should not be shared
e. Laundry all the bedding and clothing in hot water and dry on high heat
f. Vacuum floors, play areas, and Furniture to remove any hairs that may carry live nits

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287. The nurse is reinforcing home care instructions to the parents of a three-year-old child with
scabies. Which statement by a parent indicates the need for further teaching?
a. “I understand that I need to leave the scabicide on for 4 hours before washing it off”
b. “I will need to seal up all of my child's non washable toys in a plastic bag for at least 4 days”
c. “I realize that everyone who has come in contact with my child will need to be treated for
scabies”
d. “I know I need to wash all the clothing and bedding in hot water with detergent and dry in a
hot dryer”

288. The nurse caring for a child who sustained a burn injury plans care based on which pediatric
considerations associated with this injury? Select all that apply
a. Scarring is less severe and a child than an adult
b. A delay in growth may occur after a burn injury
c. An immature immune system presented increase risk of infection for infants and young
children
d. Fluid resuscitation is unnecessary unless the burned area is more than 25% of the total body
surface area
e. The lower proportion of the body fluid to body mass in a child increases the risk of
cardiovascular problems
f. Infants and young children are at an increased risk for protein and calorie deficiency because
they have smaller muscle mass and less body fat than adults

289. A topical corticosteroid is prescribed by the healthcare provider for a child with atopic
dermatitis (Eczema). Which instruction should the nurse give the parent about applying the cream?
a. Apply the cream over the entire body
b. Apply thick layer of cream to affected areas only
c. Avoid cleansing the area before application of the cream
d. Apply a thin layer of cream and rub it into the area thoroughly

290. The nurse is assisting in performing Pediculosis capitis (Head lice) check. Which finding
indicates that a child has a “positive” head check?
a. Maculopapular lesions behind the ear
b. Lesions in the scalp that extend to the hairline on neck
c. White flaky particles throughout the entire scalp region
d. White sacs attached to the hair shafts in the occipital area

291. The nurse reinforces instructions to the parents of a child with sickle cell anemia regarding
the precipitating factors related to pain crisis. Which, if identified by a parent as a precipitating
factor, indicates the need for further teaching?
a. Stress
b. Trauma
c. Infection
d. Fluid Overload

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292. The nurse monitors a five-year-old child admitted to the hospital for a neuroblastoma for
signs and symptoms related to the location of the tumour in the adrenal gland. Which descriptions
would the nurse expect to be documented in the child’s record specific to this tumour? Select all that
apply
a. Respiratory impairment
b. Anorexia and weight loss
c. Pallor, weakness, irritability
d. Supraorbital ecchymosis and periorbital edema
e. Firm, non-tender, irregular mass in the abdomen
f. Urinary frequency retention from compression on the bladder

293. The nurse caring for a child with aplastic anemia is reviewing the laboratory results and notes
a white blood cell count of 6000 mm3 and a platelet count of 20000 mm3. Which nursing
intervention should be incorporated into the plan of care?
a. Encouraging naps
b. Encourage a diet high in iron
c. Encourage quiet play activities
d. Maintain strict isolation precautions

294. The nurse reinforces home care instructions to the parents of a three-year-old who has been
hospitalized with hemophilia. Which statement by a parent indicates the need for further teaching?
a. “I will supervise my child closely”
b. “I will pad the corners of the furniture”
c. “I will remove household items that can easily fall over”
d. “I will avoid immunizations in dental hygiene treatments for my child”

295. The nurse reinforces instructions to the parents of a child with leukemia regarding measures
related to monitoring for infection. Which statement by the parent indicates a need for further
teaching?
a. “I will use proper hand-washing techniques”
b. “I need to take my child's rectal temperature daily”
c. “I need to inspect my child's skin daily for redness”
d. “I need to check my child's mouth daily for lesions”

296. The nurse is providing discharge instructions to the parents of a fourteen-year-old child who
is undergoing radiation for Hodgkin's Disease. Which statement by a parent indicates the need for
further teaching?
a. “I need to watch for diarrhea, so my child does not get dehydrated”
b. “I think that once my child's hair starts to fall out that I can keep a hat on him”
c. “I understand that the radiation will cause nausea and vomiting and I need to keep my child
hydrated”
d. “I need to get my child's skin from flaking, so we will be allowing showers every 2 or 3
days”

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297. A four-year-old child is hospitalized with a suspected diagnosis of Wilms tumor. The nurse
reviews the plan of care and should question which intervention that is written in the plan?
a. Palpate the abdomen for a mass
b. Check the urine for presence of hematuria
c. Monitor the blood pressure for the presence of hypertension
d. Monitor the temperature for presence of a kidney infection

298. The nursing instructor asks a student nurse to describe osteogenic sarcoma. Which statement
by the student indicates the need to further research the disease?
a. The femur is the most common site of this sarcoma
b. The child does not experience pain at the primary tumour site
c. If a weight-bearing limb has affected, then limping as a clinical manifestation
d. The symptoms of the disease during the early stage are almost always attributed to normal
Growing Pains

299. The nurse is monitoring for bleeding in a child after surgery to remove a brain tumour. The
nurse checks the head dressing for presence of blood and notes colorless drainage on the back of the
dressing. Which nursing action is appropriate?
a. Reinforce the dressing
b. Notify the RN
c. Document the findings and continue to monitor
d. Circle area drainage and continue to monitor

300. The nurse observes a mother giving an oral iron supplement to a 6 year old child with iron
deficiency anemia. Which action by the mother indicates the need for further teaching?
a. The mother administered the iron with milk
b. The mother administered the iron with water
c. The mother administered the iron with apple juice
d. The mother administered the iron with orange juice

301. A school-age child with type 1 diabetes mellitus has soccer practice three afternoons a week.
The nurse reinforces instructions regarding how to prevent hypoglycemia during practice. Which
should the nurse tell the child?
a. Drink a half cup of orange juice before soccer practice
b. Eat twice the amount that is normally eaten at lunch time
c. Take half of the amount of prescribed insulin on practice days
d. Take the prescribed insulin at noon time rather than in the morning

302. The nursing instructor asks a nursing student about phenylketonuria. Which statement made
by the student indicates a need for further teaching?
a. “PKU is an autosomal recessive disorder”
b. “PKU primarily affects the GI system”
c. “Treatment of PKU indicates the dietary restrictions of phenylalanine”
d. “All 50 states require a routine screening of all newborns for PKU”

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303. The mother of a six-year-old child with type 1 diabetes mellitus calls a clinic nurse and tells
the nurse that the child has been sick. The mother reports that she checked the child's urine and it
was positive for ketones. The nurse should instruct the mother to take which action?
a. Hold the next dose of insulin
b. Come to the clinic immediately
c. Encourage the child to drink liquids
d. Administer an additional dose of regular insulin

304. The healthcare provider prescribes an IV solution of 5% dextrose in half normal saline
(0.45%) with 40 mEq of potassium chloride for a child with hypertonic dehydration. The nurse
performs which priority assessment before administering this IV prescription?
a. Obtains the weight
b. Takes the temperature
c. Takes the blood pressure
d. Checks the amount of urine output

305. An adolescent client with type 1 diabetes mellitus is admitted to the emergency department
for treatment of diabetic ketoacidosis. Which assessment finding should the nurse expect to note?
a. Sweating and tremors
b. Hunger and hypertension
c. Cold, clammy skin and irritability
d. Fruity breath odor in decreasing level of consciousness

306. A mother brings her three-week-old infant to a clinic for phenylketonuria rescreening blood
test. The test indicates a serum phenylalanine level of 0 mg/dL. The nurse reviews this result and
makes which interpretation?
a. It is negative
b. It is a concern
c. It is inconclusive
d. It requires rescreening at age 6 weeks

307. A child with type 1 diabetes mellitus is brought to the emergency department by the mother,
who states that the child has been complaining of abdominal pain and has been lethargic. Diabetic
ketoacidosis is diagnosed. Anticipating the plan of care, the nurse prepares to administer which type
of IV infusion ?
a. Potassium infusion
b. NPH insulin infusion
c. 5% dextrose infusion
d. Normal saline infusion

308. The nurse has just administered ibuprofen to a child with a temperature of 38.8 C. The nurse
should also take which action?
a. Withhold oral fluids for 8 hours
b. Sponge the child with cold water
c. Plan to administer salicylate in 4 hours
d. Remove excess clothing and blankets from the child

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309. A child has a fluid volume deficit. The nurse collects data and determines the child is
improving and the deficit is resolving if which finding is noted?
a. The child has no tears
b. Urine specific gravity is 1.030
c. Capillary refill is less than 2 seconds
d. Urine output is less than 1 ml/kg/hr

310. The nurse should implement which interventions for a child older than two years with type 1
diabetes mellitus who has a blood glucose level of 60 mg/dL? Select
a. Administer regular insulin
b. Encourage the child to ambulate
c. Give the child a teaspoon of honey
d. Provide electrolyte replacement therapy intravenously
e. Wait 30 minutes and come from the blood glucose reading
f. Prepare to administer glucagon subcutaneously if unconsciousness occurs

311. The nurse is reviewing the post operative Primary Health Care provider's prescriptions for a
three-week-old infant with hirschsprung’s disease and is admitted to the hospital for surgery. Which
prescriptions documented in the child's record should the nurse question?
a. Measure abdominal girth daily
b. Monitor strict intake and output
c. Take temperature measurements rectally
d. Start clear liquid diet after 8 hours postoperative
e. Maintain IV fluids until the child tolerates oral intake
f. Monitor the surgical site for redness, swelling, and drainage

312. The nurse is monitoring for signs of dehydration in a one year old child who has been
hospitalized for diarrhea and prepares to take the child's temperature. Which method of temperature
measurement should be avoided?
a. Rectal
b. Axillary
c. Electronic
d. Tympanic

313. A mother of a child with a diagnosis of intussusception causes the nurse into the hospital
room because the child is screaming in pain. Which manifestations of perforation should the nurse
report immediately? Select all that apply
a. Fever
b. Ribbon like stools
c. Increased heart rate
d. Hypoactive bowel sounds
e. Profuse projectile vomiting
f. Change in the level of consciousness

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314. A child with a diagnosis of a hernia has been scheduled for a surgical repair in 2 weeks. The
nurse reinforces instructions to the parents about the signs of possible incarcerated hernia. The nurse
tells the parents that which manifestation requires the PHCP notification by the parents?
a. Pain
b. Diarrhea
c. Constipation
d. Increase flatus

315. The nurse reinforces home care instructions to the parents of a child with hepatitis regarding
the care of the child and the prevention of the transmission of the virus. Which statement by a parent
indicates a need for further teaching?
a. “Frequent hand-washing is important”
b. “I need to provide a well-balanced, high-fat diet to my child”
c. “I need to clean contaminated household surfaces with bleach”
d. “Diaper should not be changed near any services that are used to prepare food”

316. The nurse is assigned to care for a child who is scheduled for an appendectomy. Which
prescriptions does the nurse anticipate to be prescribed? Select all that apply
a. Administer a Fleet enema
b. Initiate an IV line
c. Maintain Nothing by mouth status
d. Administer IV antibiotics
e. Administer preoperative medications
f. Place a heating pad on the abdomen to decrease pain

317. A child is brought to the emergency room and the mother reports that the child accidentally
swallowed paint thinner after mistaking it for water. The nurse should perform which action first?
a. Begin resuscitation
b. Terminate exposure to the poison
c. Take measures to prevent absorption of the poison
d. Check the circulation, Airway, and breathing status of the child

318. The nurse is caring for an 18 month old child who has been vomiting. Which is the
appropriate position to place a child in during naps and sleep time?
a. A Supine position
b. A side-lying position
c. Prone, with the head elevated
d. Prone, with the face turned to the side

319. An infant returned to the nursing unit after the surgical repair of a cleft lip located on the right
side of the lip. Which is the best position to place this infant at this time?
a. A flat position
b. The prone position
c. On his or her left side
d. On his or her right side

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320. The nurse reviews the record of an infant who is seen in the clinic. The nurse notes that the
diagnosis of esophageal atresia with tracheoesophageal fistula is suspected. The nurse expects to note
which most likely manifestation of this condition in the medical record?
a. Incessant crying
b. Coughing at night time
c. Choking with feedings
d. Severe projectile vomiting

321. The nurse is reviewing the record of a child with a diagnosis of pyloric stenosis. Which data
should the nurse expect to note as having been documented in the child's record?
a. Watery diarrhea
b. Projectile vomiting
c. Increased urine output
d. Vomiting large amounts of bile

322. The nurse reinforces instructions to the mother about dietary measures for a five-year-old
child with lactose intolerance. The nurse should tell the mother that which supplement will be
required as a result of the need to avoid lactose in the diet?
a. Fats in vitamin A
b. Zinc and vitamin C
c. Calcium and vitamin D
d. Thiamine in vitamin B

323. The nurse reinforces home care instructions to the parents of a child with celiac disease.
Which food item should the nurse advise the parents to include in the child's diet?
a. Rice
b. Oatmeal
c. Rye toast
d. Wheat bread

324. The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused
by the respiratory syncytial virus. Which intervention should be included in the plan of care? Select
all that apply
a. Place the infant in a private room
b. Place the infant in a room near the nurses station
c. Ensure that the infant's head is in a flexed position
d. Wear a mask at all times when in contact with the infant
e. Place the child in a tent that delivers warm, humidified air
f. Position the infant side lying, with the head lower than the chest

325. After tonsillectomy, the child begins to vomit bright red blood. Which is the initial nursing
action?
a. Turn the child to the side
b. Notify the RN
c. Administer the prescribed antianemic
d. Maintain NPO status

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326. The nurse reinforces instructions to the mother of a child with croups about the measures to
take if an acute spasmodic episode occurs. Which statement by the mother indicates the need for
further teaching?
a. “I will take my child into the humid night air”
b. “I will place a steam vaporizer in my child's bedroom”
c. “I will place a cool mist humidifier in my child's bedroom”
d. “I will place my child in a closed bathroom and allow my child to inhale Steam from the
running water”

327. The nurse reinforces instructions to the mother of a child who has been hospitalized with
croup. Which statement made by the mother would indicate the need for further teaching?
a. I will give my child cough syrup if a cough develops
b. During an attack, I will take my child to a cool location
c. I can give acetaminophen if my child develops a fever
d. I'll be sure that my child drinks at least three to four glasses of fluids everyday

328. The nurse is working in the emergency department is caring for a child who has been
diagnosed with epiglottitis. Which is an indication that the child may be experiencing Airway
obstruction?
a. Retractions and coughing
b. Nasal flaring and bradycardia
c. Tripod positioning and dyspnea
d. A low-grade fever and complains of sore throat

329. The nurse has provided instructions to the mother of an infant With viral pneumonia. Which
statement by the mother would indicate the need for further teaching?
a. “I understand I will need to have my baby on antibiotics for this pneumonia”
b. “I will need to give a cough suppressant before meals if his cough gets too bad”
c. “I'll be careful and allow my baby to sleep, so he can conserve energy and fight this
infection”
d. “I understand that my baby has viral pneumonia and I need to monitor his temperature
because of the risk for febrile seizures”

330. The nurse is instructing the mother of a child with cystic fibrosis about the appropriate
dietary measures. Which meal best illustrates the most appropriate diet for a client with cystic
fibrosis?
a. Veggie salad and a caramel apple
b. Strawberry jelly sandwich and pretzels
c. Plate of nachos and cheese and a cupcake
d. Chicken tenders and a baked potato with butter

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331. The nursing instructor asks a nursing student about sudden infant death syndrome. Which
statement by the student indicates further teaching is needed?
a. “Some of the interventions that are used to prevent SIDS include having infant sleep in the
Supine position”
b. “The incidence of SIDS has been found to be the higher in breastfed infants and infants that
use a pacifier”
c. “Infants exposed to cigarette smoking during pregnancy and after birth are considered at risk
for SIDS”
d. “SIDS refers to sudden infant death syndrome that can occur in healthy infants under 1 year
of age, and no exact cause is known”

332. Isoniazid is prescribed for a two-year-old child with a positive tuberculin skin test. The
mother of the child asks the nurse how long the child will need to take the medication. Which time
frame is the appropriate response to the mother?
a. 4 months
b. 9 months
c. 12 months
d. 18 months

333. The nurse is instructing a mother of a one-year-old child with strabismus about the treatment
options. Which statement by the mother would indicate the need for further teaching?
a. “My child will outgrow this by the time he's two years old and be able to see just fine”
b. “I will have my child wear an eye patch over the good eye to help strengthen the weak eye”
c. “If his eye patch does not work I know that we will have to do surgery to correct my child's
cross eyes”
d. “There are a few cases of this condition and they told me my child has crossed eyes because
of a muscle imbalance”

334. The nurse has provided instructions to the mother of a child who has been diagnosed with
bacterial conjunctivitis. Which statement by the mother would indicate the need for further teaching?
a. “I need to wash my hands frequently”
b. “I need to clean the eye, as prescribed”
c. “I need to give the eye drops, as prescribed”
d. “I need to use hot compresses to relieve the eye irritation”

335. The nurse is assigned to care for a child after myringotomy with the insertion of
tympanostomy tubes. The nurse notes a small amount of reddish drainage from the child's ear after
the surgery. On the basis of this finding, which action should the nurse take?
a. Document the findings
b. Notify the RN immediately
c. Change the ear tubes so that they do not become blocked
d. Check the age range for the presence of cerebrospinal fluid

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336. The nurse is supposed to prepare a teaching plan regarding the administration of ear drops for
the parents of a two-year-old child with otitis media. Which should be included in the plan?
a. Wear gloves when administering ear drops
b. Pull the ear up and back before and still in the ear drops
c. Pull the earlobe down and back before instilling ear drops
d. Hold the child in the sitting position when administering ear drops

337. The nurse reviews the record of a child who has just been seen by the PHCP. The PHCP has
documented a diagnosis of suspected aortic stenosis. Which specific signs / symptoms of aortic
stenosis should the nurse anticipate?
a. Pallor
b. Hyperactivity
c. Exercise intolerance
d. GI disturbances

338. The nurse has reinforced home care instructions to the parents of a child who is being
discharged after cardiac surgery. Which statement by the parent indicates the need for further
teaching?
a. “A balance of rest and exercise is important”
b. “I can apply lotion or powder to the incision if it is itchy”
c. “Activities during which the child could fall need to be avoided for 2 to 4 weeks”
d. “Large crowds of people need to be avoided for at least 2 weeks after the surgery”

339. The nurse is told that a child with rheumatic fever will be arriving at the nursing unit for
admission. Which question should the nurse ask the family to elicit information specific to the
development of RF?
a. “Has the child complained of back pain?”
b. “Has the child complained of headaches?”
c. “Has the child had any nausea or vomiting?”
d. “Has the child had a sore throat or a fever within the past 2 months?”

340. The nurse is providing instructions to a parent of a child with patent ductus arteriosus. Which
statement by the parent would indicate a need for further teaching?
a. “I know that my child will outgrow this problem, just give him time”
b. “I know that I need to be alert for signs of heart failure with this defect until it is repaired”
c. “The doctors told me that my child has a heart murmur caused by the ductus not closing after
birth”
d. “As I understand it, my child may have to have his defect closed, either during a
catheterization or by surgery”

341. The nurse is admitting a child with a diagnosis of acute stage Kawasaki disease. When
obtaining the child's medical history, which manifestation is likely to be noted?
a. Cracked lips
b. A normal appearance
c. Conjunctival hyperemia
d. Desquamation of the skin

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342. The nurse caring for an infant with congenital heart disease is monitoring the infant closely
for signs of heart failure. The nurse should observe for which early sign of heart failure? Select all
that apply
a. Cough
b. Irritability
c. Scalp diaphoresis
d. Tachypnea, tachycardia
e. Slow and shallow breathing

343. The nurse was caring for an infant who had come to the nursing unit for observation and
treatment of tetralogy of fallot. The child suddenly becomes cyanotic and the oxygen saturation
reading drops to 60%. The nurse should perform which action first?
a. Assist to administer morphine sulphate
b. Place the child in a knee to chest position
c. Administer 100% Oxygen by face mask
d. Prepare to administer IV fluids

344. The nurse is monitoring the daily weight of an infant with heart failure. Which finding alerts
the nurse to suspect fluid accumulation and thus the need to notify the registered nurse?
a. Bradypnea
b. Diaphoresis
c. Decrease blood pressure
d. A weight gain of one pound in one day

345. The nurse provides home care instructions to the parents of a child with heart failure
regarding the procedure for the administration of digoxin. Which statement by a parent indicates the
need for further teaching?
a. “I will not mix the medication with food”
b. “If more than one dose is missed, I will call the doctor”
c. “I will take my child's pulse before administering the medication”
d. “If my child vomits after medication administration, I will repeat the dose”

346. A healthcare provider has prescribed oxygen as needed for a 10 month old infant with heart
failure. In which situation should the nurse administer the oxygen to the child?
a. When the child is sleeping
b. When changing the child's diaper
c. When the mother is holding the child
d. When drawing blood for electrolyte levels

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347. The nurse is assigned to care for a child who is suspected of having glomerulonephritis. The
nurse reviews the child's record and notes which findings are associated with the diagnosis of
glomerulonephritis? Select all that apply
a. Headache
b. Hypotension
c. Red brown urine
d. Periorbital edema
e. Increase urine output
f. A low blood urea nitrogen level

348. A child is admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which
finding should the nurse expect to observe? Select all that apply
a. Ascites
b. Anorexia
c. Weight loss
d. Proteinuria
e. Decreased serum lipids
f. Periorbital and facial edema

349. The nurse is planning care for a child with hemolytic-uremic syndrome. The child has been
anuric and will be receiving a peritoneal dialysis treatment. The nurse should plan to include which
interventions in the care of the child? Select all that apply
a. Provide adequate nutrition
b. Restriction of fluids, as prescribed
c. Institute measures to prevent infection
d. Monitoring that arteriovenous fistula
e. Administer blood products to treat severe anemia
f. Anticipate the child will have central nervous system involvement

350. The nurse is assisting with Gathering admission assessment data on a two-year-old child who
has been diagnosed with nephrotic syndrome. the nurse collects data knowing that which is a
common characteristic associated with nephrotic syndrome?
a. Hypotension
b. Generalized edema
c. Increased urinary output
d. Frank, bright red blood in the urine

351. The childless cryptorchidism is being discharged after orchiopexy, which was performed on
an outpatient basis. The nurse should reinforce instructions to the parents. Which Priority Care
measure?
a. Measuring intake and output
b. Administering anticholinergics
c. Preventing infection at the surgical site
d. Applying cold, wet compresses to the surgical site

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352. The nurse is reinforcing discharge instructions to the parents of a two-year-old child who has
had an orchiopexy to correct cryptorchidism. Which statement by the parent indicates a need for
further teaching?
a. “I’ll take his temperature”
b. “I'll give him medication so he'll be comfortable”
c. “I'll let him decide when to return to his play activities”
d. “I'll check his boarding to be sure there are no problems”

353. The nurse collects a urine specimen preoperatively from a child with epispadias who is
scheduled for surgical repair. The nurse reviews the child's record for the laboratory results of the
urine test and would most likely expect to note which finding?
a. Hematuria
b. Bacteriuria
c. Glucosuria
d. Proteinuria

354. An 18 month old child is being discharged after surgical repair of hypospadias. Which post-
operative nursing care measures should the nurse stress to the parents as they prepare to take this
child home?
a. Leave diapers off to allow the site to heal
b. Avoid tub bath until the stent has been removed
c. Encourage toilet training to ensure that the flow of urine is normal
d. Restrictive food intake to reduce urinary output for the first few days

355. The parents of a newborn have been told that their child was born with bladder exstrophy and
the parents ask the nurse about this condition. Which response should the nurse give to the parents
about bladder exstrophy?
a. “It is a hereditary disorder that occurs in every other generation”
b. “Is caused by the use of medications taken by the mother during pregnancy”
c. “It is a condition in which the urinary bladder is abnormally located in the pelvic cavity”
d. “It is an extrusion of the urinary bladder to the outside of the body through a defect in the
lower abdomen wall”

356. A parent with a six-year-old child diagnosed with enuresis discusses with the nurse the
measures that are being taken to help her child. Which statement by the parent indicates a need for
further teaching?
a. “I will make sure that my child goes potty before going to bed”
b. “I have my child help with changing the wet sheets in the morning”
c. “I will take away privileges such as TV time when their bed is wet in the morning”
d. “I make sure that my child does not have anything to drink 2 hours before bedtime”

357. The nurse instructs a mother of a child who has seizures regarding seizure precautions.
Which statement by the mother indicates a need for further teaching?
a. “I will make my child wear medical identification Alert bracelet”
b. “I know that my child will need to have a companion when swimming”
c. “I will need to give anti-seizure medications when my child has a seizure”
d. “I will have my child wear a bike helmet when riding a bike or skateboarding”

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358. A child has a basilar skull fracture. Which primary health care provider prescription should
the nurse question?
a. Restrict fluid intake
b. Insert an indwelling urinary catheter
c. Keep an IV line patent
d. Suction via the nasotracheal route as needed

359. Which laboratory result would verify the diagnosis of bacterial meningitis?
a. Clear cerebrospinal fluid with high protein and low glucose levels
b. Cloudy cerebrospinal fluid with low protein and low glucose levels
c. Cloudy cerebrospinal fluid with high protein and low glucose levels
d. Decrease pressure in Cloudy cerebrospinal fluid with high protein level

360. The nurse reinforces instructions to the parents of a child with meningococcal meningitis.
Which statement by the parent indicates a need for further teaching?
a. “I can give my child acetaminophen for fever”
b. “I will watch for any hearing loss that may occur”
c. “I know that I will need to watch for any rash my child May develop”
d. “I will need to get my other children the pneumococcal vaccine, but not the baby yet, he is
only 3 months”

361. The parents of a child recently diagnosed with cerebral palsy ask the nurse about the disorder.
The nurse bases the response on the understanding of cerebral palsy is which type of condition?
a. An infectious disease of the central nervous system
b. An inflammation of the brain as a result of viral illness
c. A congenital condition that results in moderate to severe retardation
d. A chronic disability that characterized by impaired muscle movement and posture

362. The nurse is reviewing the post-operative prescriptions for an infant with hydrocephalus, who
came back from surgery with a ventriculoperitoneal shunt. Which of the Primary Health Care
provider's prescriptions does the nurse question?
a. Position the infant on the inoperative side
b. Keep the head of the bed elevated 45 degrees
c. Monitor for signs of infection and check dressings for drainage
d. Observe for irritability, a high shrill cry, lethargy, and poor feeding

363. The nurse is reviewing the record of a child with increased intracranial pressure and notes
that the child has exhibited signs of deceberate posturing. During data collection about the child, the
nurse expects to note which characteristic of this type of posturing?
a. Flaccid paralysis of all extremities
b. Adduction of the arms of the shoulder
c. Rigid extension and pronation of the arms and legs
d. Abnormal flexion of the upper extremities and extension and adduction of the lower
extremities

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364. A child is diagnosed with Reye’s syndrome. The nurse assists with developing a nursing care
plan for the child and should include which intervention in the plan?
a. Assess hearing loss
b. Monitor urine output
c. Change body position every 2 hours
d. Provide a quiet atmosphere with dimmed lighting

365. The nurse provides home care instructions to the parents of a child with attention deficit
hyperactivity disorder regarding behavioral therapy interventions. Which statement by the parent
indicates a need for further teaching?
a. “I hear that the side effects of the medication that my child will be on can cause overeating”
b. “I know that it consistent medication and regular follow-up visits are a part of the plan for my
child”
c. “I know I need to maintain a consistent home environment because my child is easily
distracted”
d. “I understand that I will need to learn some behavioral modification techniques to help my
child impulsivity”

366. The nurse is reinforcing instructions to the parents of a child with scoliosis regarding the use
of a brace. Which statement by a parent indicates the need for further teaching?
a. “I need to have my child wear a soft fabric under the brace”
b. “I will apply lotion under the brace to prevent skin breakdown”
c. “I need to encourage my child to perform the prescribed exercises”
d. “I need to avoid applying powder under the brace, because it will cake”

367. The mother of a child with juvenile idiopathic arthritis calls the nurse because the child is
experiencing a painful exacerbation of the disease. The mother asks the nurse if the child should
perform a range of motion exercises at the time. The nurse should make which response to the
mother?
a. “Avoid all exercise during painful periods”
b. “The range of motion exercises must be performed every day”
c. “Have the child perform simple isometric exercises during this time”
d. “Administer additional pain medication before performing range of motion exercises”

368. A four-year-old child sustains off all at home and injures the right arm and is brought to the
emergency department by the mother. The nurse should perform which emergency actions in the
care of the child? Select all that apply
a. Elevate the right arm
b. Apply warm packs to the right arm
c. Check the neurovascular status of the right extremity
d. Check the range of motion of the right arm and shoulder
e. Determine the level of pain using a pediatric pain assessment tool

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369. The nurse is to create a nursing care plan for a child with an arm cast and should include
which interventions in the plan? Select all that apply
a. Instruct parents to keep the cast clean and dry
b. Monitor the extremity for circulatory impairment
c. Instruct child not to stick objects down the cast
d. Ensure that roughcast materials are cut off to keep smooth
e. Notify the RN immediately if circulatory impairment occurs

370. The mother of a child with Marfan syndrome asks the nurse what can be done to help her
child. Which of the best responses by the nurse? Select all that apply
a. “You may need to consider surgery in the future”
b. “You will need to make regular pediatric appointments for your child”
c. “You need to keep your child indoors and avoid Sports”
d. “You will need to make regular eye examination appointments for your child”
e. “You will need to have your child take cardiac medications to decrease stress on the aorta”
f. “You need to let the dentist know that antibiotics should be given before any procedure”

371. The nurse is assessing the PHCP during an examination of an infant with hip dysplasia. The
PHCP performs the ortolani manoeuvre. Which data should the nurse expect to note during the
examination?
a. Full range of motion of the legs
b. Marked asymmetry on the affected side
c. The unstable femoral head pops out of the acetabulum
d. The dislocated femoral head pops back into the acetabulum

372. The nurse provides information to the parent of a two-week-old infant who is diagnosed with
clubfoot at the time of birth. Which statement by the parent indicates the need for further teaching
regarding this disorder?
a. “I understand treatment needs to be started as soon as possible”
b. “I realize my child will require follow-up care until full grown”
c. “I need to bring my child back to the clinic in 1 month for a new cast”
d. “I need to come to the clinic every week with my child for the casting”

373. Nurse reinforces home care instructions to the parents of a child with a brace for scoliosis.
Which statement by a parent indicates a need for further teaching?
a. I will inspect the skin under the brace for redness or breakdown
b. I will encourage my child to do their exercises to maintain strength
c. I understand that my child needs to wear this brace for 12 hours a day
d. I understand that this brace is not a cure for scoliosis, it only slows the progression of the
curvature
374. The nurse is assigned to care for a child who is in skeletal traction. The nurse needs to avoid
which action when caring for the child?
a. Keeping the weights hanging freely
b. Ensuring that the ropes are in the pulleys
c. Placing the bed linens on the traction ropes
d. Ensuring that the weights are out of the child's reach

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375. The nurse is performing a neurovascular check on a hospitalized child who had a cast applied
to the lower leg. The child complains of tingling in the toes distal to the fracture site. Which action
should the nurse take?
a. Elevate the extremity
b. Document the findings
c. Notify the RN
d. Ambulate the child with crutches

376. A child with rubeola (measles) is being admitted to the hospital. When preparing for the
admission of this child, which precaution should be implemented? Select all that apply
a. Enteric
b. Contact
c. Airborne
d. Protective
e. Neutropenic

377. The mother of a toddler with mumps asks the nurse what she needs to watch for in her child
with this disease. The nurse bases the response on the understanding that month is which type of
communicable disease?
a. Skin rash caused by a virus
b. Skin rash caused by a bacteria
c. Respiratory disease caused by virus involving the lymph node
d. Respiratory disease caused by a virus involving the parotid gland

378. A six-month-old infant receives diphtheria, tetanus, and acellular pertussis (TDAP)
immunization at the baby Clinic. The parent returns home and calls the clinic to report that the infant
has developed swelling and redness at the site of injection. Which instruction by the nurse is
appropriate?
a. Monitor the infant for a fever
b. Bring the infant back to the clinic
c. Applying ice pack to the injection site
d. Leave the injection site alone, because this always occurs

379. A child is diagnosed with scarlet fever. The nurse collects data regarding the child. Which is
characteristic of scarlet fever?
a. Pastia's sign
b. Abdominal pain and flaccid paralysis
c. Dense pseudo formation membrane in the throat
d. Foul-smelling in mucopurulent nasal drainage

380. A child is diagnosed with infectious mononucleosis. The nurse reinforces home care
instructions to the parents about the care of the child. Which instruction should the nurse provide to
the parents?
a. Maintain the child on bed rest for 2 weeks
b. Maintain respiratory precautions for 1 week
c. Notify the pediatrician If the child develops a fever
d. Notify the pediatrician If the child develops abdominal or left shoulder pain

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381. A child is diagnosed with chickenpox. The nurse collects data regarding the child. Which
finding is characteristic of chickenpox?
a. Macular rash on the trunk and scalp
b. Pseudomembrane formation in the throat
c. Maulopapular or petechial rash on the extremity
d. Small, red spots with a bluish White Center and red base

382. The nurse is reviewing instructions to a parent of a six-year-old on how to prevent influenza.
Which statement by the parent indicates a need for further teaching?
a. I will get a flu shot and will have my child get a flu shot too
b. I will avoid having my child come in contact with sick children
c. I will have my child wash her hands frequently during the flu season
d. I will not let my child play with other children who have the flu unless they're taking
acetaminophen

383. The nurse reviews measures to prevent tick bites with a parent of a child with Rocky
Mountain Spotted Fever. Which statement by the parent indicates a need for further teaching?
a. I will have my child wear long sleeves and long pants to keep covered up
b. I won't have my child stay on well worn paths and not stray into Tallgrass
c. I will check my child for ticks after being exposed to a high-risk tick infected area
d. I will have my child wear dark coloured clothing so the tick will not be attracted to the
colours

384. Which home care instructions should the nurse plan to reinforce to the mother of a child with
acquired immunodeficiency syndrome (AIDS)? Select all that apply
a. Frequent hand-washing is important
b. The child should avoid exposure to other illnesses
c. The child immunization schedule will need revision
d. Kissing the child on the mouth will never transmit the virus
e. Clean up body fluids spills with bleach solution 10 to 1 ratio of water to bleach
f. Fever, malaise, fatigue, weight loss, vomiting, and diarrhea are expected to occur and do not
require special intervention

385. The nurse reviews the home care instructions with the parents of a three-year-old with
pertussis. Which statement by the parent indicates a need for further teaching?
a. I know that my child will make a loud whooping sound
b. I understand this whooping cough is viral and I have to let it run its course
c. I understand that I need to watch for respiratory distress signs with pertussis
d. I can reduce the environmental factors that can trigger coughing, like Dust and Smoke

386. Morphine sulphate, 2.5 mg, is prescribed for a child. The safe pediatric dose is 0.05
mg/kg/dose to 0.1 mg/kg/dose. The child weighs 50 kilograms. Which statement accurately describes
the prescribed dosage for this child?
a. The dose is too low
b. The dose is too high

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 c. The dose is within the safe dosage range
d. There is not enough information to determine the safe dosage range
387. The PHCP’s prescription reads acetaminophen 240 mg orally every 6 hours as needed for
relief of pain, for a five-year-old child. The medication label reads acetaminophen 160 mg per 5 ml.
How many millilitres per dose should the nurse administer the child?
Answer __________ mL

388. The primary healthcare provider has prescribed phenobarbital sodium, 25 mg orally twice
daily, for a child with febrile seizures. The medication label reads as follows: phenobarbital sodium,
20 mg per 5ml. The nurse has determined that the dose prescribed is a safe dose for the child. How
many millilitres per dose should the nurse administer to the child?
Answer __________ mL

389. Sulfisoxazole one gram orally four times daily, is prescribed for an adolescent with a urinary
tract infection. The medication label reads 250 mg tablets. The nurse has determined that the
prescribed dose is safe. How many tablets per dose should the nurse administer to the Adolescent?
Answer __________ tablets

390. The primary healthcare provider has prescribed an antibiotic for a child. The average adult
dose is 500 mg. The child has a body surface area of 0.63 M squared. What is the dose for the child?
Answer __________ mg

391. An adult client was burned as a result of an explosion. The burn initially affected the client's
entire face, the anterior have the head and the upper half of the anterior torso, and there were
circumferential burns to the lower half of both arms. The client's clothes caught on fire and the client
ran, which caused subsequent burn injuries to the posterior surface of the head and the upper half of
the posterior torso. According to the rule of Nines, what is the extent of his clients brain injury? Fill
in the blank
Answer __________ %

392. The nurse, employed in a long-term care facility, is planning the clinical assignments for the
day. The nurse knows not to assign which staff member to the client with a diagnosis of herpes
zoster?
a. A staff member who has never had roseola
b. A staff member who has never had mumps
c. An unlicensed assistive Personnel who has never had chickenpox
d. An unlicensed assistive Personnel who has never had German Measles

393. A client returns to the clinic for a follow-up treatment after skin biopsy of suspicious lesion
that was performed one week ago. The biopsy report indicates that the lesion is a melanoma. The
nurse understands which characteristic describes this type of lesion? Select all that apply
a. Metastasis is rare
b. It is encapsulated
c. It is highly metastatic
d. It is characterized by local invasion
e. Lesion is a nevus that is changed in colour

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394. The nurse is reviewing the health-care record of a client with a lesion that has been diagnosed
as Basal cell carcinoma. The nurse should expect which characteristics of this type of lesion to be
documented in the client's record? Select all that apply.
a. Lesion has a waxy border
b. An irregularly shaped lesion
c. Papule, with a red, Central crater
d. A small papule with a dry, rough scale
e. A firm nodular lesion topped with a crust

395. The nurse reinforces instructions to a group of clients regarding measures that will assist with
the prevention of skin cancer. Which statement by a client indicates the need for further teaching?
a. I need to wear sunscreen when participating in outdoor activities
b. I need to avoid sun exposure before 10 a.m. and after 4 p.m.
c. I need to wear a hat, opaque clothing, and sunglasses when in the Sun
d. I need to examine my body monthly for any lesions that may be suspicious

396. A client arrives at the emergency department and has experienced frostbite to the right hand.
What should the nurse expect to find when inspecting the client’s hand?
a. A pink, edematous hand
b. Fiery red skin with edema in the nail beds
c. Black fingertips surrounded by an erythematous rash
d. A white colour of the skin which is insensitive to touch

397. The evening nurse reviews the nursing documentation in the client's chart and notes that the
day nurse has documented that the client has a stage 2 pressure injury in the sacral area. What should
the nurse expect to find when checking the clients sacral area?
a. Intact skin
b. The presence of tunneling
c. A deep, crater like appearance
d. Partial thickness skin loss of the epidermis

398. The nurse expects the skin of a client who is suspected of having psoriasis. Which finding
should the nurse know if this disorder is present?
a. Oily skin
b. Silvery white scaly lesions
c. Patchy hair loss and round, red macules with scales
d. The presence of wheal patches scattered about the trunk

399. The nurse is told that an assigned client is suspected of having methicillin-resistant
staphylococcus aureus (MRSA). Which precaution should the nurse institute during the care of this
client?
a. Wear gloves only
b. Wear a mask and gloves
c. Wear a gown and gloves
d. Avoid touching the clients clothes

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400. The client arrives at the emergency department after a burn injury that occurred in their home
basement and an inhalation injury is suspected. Which should the nurse anticipate as being
prescribed for the client?
a. Oxygen via nasal cannula at 10 L
b. Oxygen via nasal cannula at 15 L
c. 100% oxygen via an aerosol mask
d. 100% oxygen via a tight-fitting, nonrebreather face mask

End of Test #2!

Yay!!!!

Keep Studying!

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 Saunders Exam Practice Questions Test #3
401. The nurse is caring for a client who has just been admitted to the nursing unit after receiving
flame Burns to the face and chest. The nurse notes a horse cough, and the client is a decorating
sputum with black flecks. The client suddenly becomes restless and his colour is becoming Dusky.
Based on this data, and which interpretation should the nurse make?
a. The client is hypotensive
b. Pain is present from the burn injury
c. The burn has probably caused a laryngeal edema, which has occluded the airway
d. The client is afraid and is having a panic attack as a result of the unfamiliar surroundings

402. Which of the anticipated therapeutic outcomes of an escharotomy procedure performed for a
circumferential arm burn?
a. The return of distal pulses
b. Decreasing edema formation
c. Brisk bleeding from the injury site
d. The formation of granulation tissue

403. The nurse is caring for a client with circumferential Burns of both legs. Which leg position is
appropriate for this type of burn?
a. A dependant position
b. Elevation of the knees
c. Flat without elevation
d. Elevation above level of the heart

404. The nurse is assisting in caring for a client who is receiving IV fluids who has sustained full
thickness burn injuries of the back and legs. The nurse understands which would provide the most
reliable indicator for determining the adequacy of the fluid resuscitation?
a. Vital signs
b. Urine output
c. Mental status
d. Peripheral pulses

405. The nurse is assigned to care for a client with herpes zoster. Based on an understanding of
this cause of this disorder, the nurse determines that this definitive diagnosis is made by which
diagnostic test?
a. Positive patch test
b. Positive culture results
c. Abnormal biopsy results
d. Wood's light examination indicate of infection

406. Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the
client, knowing that which finding indicates the presence of systemic toxicity from this medication?
a. Tinnitus
b. Diarrhea
c. Constipation
d. Decreased respirations

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407. The health education nurse provides instructions to a group of clients regarding measures that
will assist with preventing skin cancer. Which instruction should the nurse provide? Select all that
apply
a. Sunscreen should be applied every 8 hours
b. Use sunscreen when participating in outdoor activities
c. Wear a hat, opaque clothing, and sunglasses when in the Sun
d. Avoid sun exposure in the late afternoon and early evening hours
e. Examine your body monthly for any lesions that may be suspicious

408. Silver sulfadiazine is prescribed for a client with a brain injury. Which laboratory finding
requires the need for monitoring by the nurse?
a. Glucose level of 99 mg/dL (5.5 mmol/L)
b. Platelet level of 300,000 mm3 (300 x 10^9 / L)
c. Magnesium level of 1.5 mEq/L (0.75 mmol/L)
d. White blood cell count of 3000 mm3 (3.0 x 10^9 /L)

409. A burn client is receiving treatments of topical mafenide acetate to the site of the injury. The
nurse monitors the client, knowing that which finding indicates the occurrence of a systemic effect?
a. Hyperventilation
b. Elevated blood pressure
c. Local rash at the burn site
d. Local pain at the burn site

410. Isotretinoin is prescribed for a client with severe acne. Before administration of this
medication, the nurse anticipates which laboratory test will be prescribed?
a. Potassium level
b. Triglyceride level
c. Hemoglobin A1c level
d. Total cholesterol level

411. A client with severe acne is seen in the clinic and the primary health care provider prescribes
isotretinoin. The nurse reviews the client's medication record and will contact their primary health
care provider if the client is also taking which medication?
a. Digoxin
b. Phenytoin
c. Vitamin A
d. Furosemide

412. The nurse is applying a topical corticosteroid to a client with eczema. The nurse should apply
the medication to which body area? Select all that apply
a. Back
b. Axilla
c. Eyelids
d. Soles of the feet
e. Palm of the hands

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413. The clinic nurse is performing an admission assessment on a client and notes that the client is
taking azelaic acid. The nurse determines which client complaint may be associated with the use of
this medication?
a. Itching
b. Euphoria
c. Drowsiness
d. Frequent urination

414. Silver sulfadiazine is prescribed for a client with a partial thickness burn and the nurse
provides teaching about the medication. Which statement made by the client indicates a need for
further teaching about the treatments?
a. The medication is an antibacterial
b. The medication will help heal the burn
c. The medication is likely to cause stinging initially
d. The medication should be applied directly to the wound

415. The camp nurse asks the children preparing to swim in the lake if they have applied
sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied
at which times?
a. Immediately before swimming
b. 5 minutes before exposure to the Sun
c. Immediately before exposure to the Sun
d. At least 30 minutes before exposure to the Sun

416. The nurse is assisting with developing a plan of care for a client with multiple myeloma.
Which nursing intervention should be included to prevent renal failure for this client? Select all that
apply
a. Encouraging fluids
b. Providing frequent Oral Care
c. Coughing and deep breathing
d. Monitoring the red blood cell count
e. Monitoring serum calcium in uric acid levels

417. The nurse is assisting with conducting a health promotion program to community members
regarding testicular cancer. The nurse determines that further teaching is needed if a Community
member states which is a sign/symptom of testicular cancer? Select all that apply
a. Alopecia
b. Back pain
c. Painless testicular swelling
d. A heavy sensation in the scrotum
e. Elevation and prostate specific antigen levels

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418. The nurse is reviewing the laboratory results of a client with leukaemia who has received a
regimen of chemotherapy. Which laboratory finding is indicative of the massive cell destruction that
occurs with chemotherapy?
a. Anemia
b. Decrease platelets
c. Increase uric acid level
d. Decreased leukocyte count

419. The client is receiving external radiation to the neck for the cancer of the larynx. The nurse
monitors the client knowing which are side/adverse effects of the external radiation? Select all that
apply
a. Dyspnea
b. Diarrhea
c. Sore throat
d. Constipation
e. Red and dry skin over the neck

420. The nurse is reinforcing instructions to a client receiving external radiation therapy. The
nurse determines that the client needs further teaching if the client states an intention to take which
action? Select all that apply
a. Eat a high protein diet
b. Avoid exposure to sunlight
c. Wash the skin with a mild soap and Pat it dry
d. Apply pressure on the radiated area to prevent bleeding
e. Avoid standing within six feet of persons under the age of 18

421. The nurse is caring for a client with an internal radiation implant. The nurse should observe
which principle? Select all that apply
a. Pregnant women are not allowed into the clients room
b. Limit the time that the client in 1 hour per 8 hour shift
c. Wear a lead apron while delivering bedside care to the client
d. Remove the dosimeter badge when entering a client's room
e. Individuals less than 16 years old are allowed in the room if they stay 6 ft away from the
client

422. The nurse provides skin care instructions to the client who is receiving external radiation
therapy. Which statement by the client indicates the need for further teaching? Select all that apply
a. I will handle the area gently
b. I will wear loose-fitting clothing
c. I will avoid the use of deodorants
d. I will limit sun exposure to 1 hour daily
e. I will apply moisturizer with a cotton tipped applicator for itching

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423. The client is hospitalized for the insertion of an internal cervical radiation implant. Giving
care, the nurse finds the radiation implant in the bed. Which is the immediate nursing action?
a. Reinsert the implant into the vagina
b. Call the primary health care provider
c. Pick up the implant with gloved hands and flush it down the toilet
d. Pick up the implant with long handled forceps and place into a lead container

424. The nurse is assisting with creating a plan of care for a client with pancytopenia as a result of
chemotherapy. The nurse should suggest including which in the plan of care? Select all that apply
a. Restricting all visitors
b. Restricting fluid intake
c. Restricting fresh fruits and vegetables in the diet
d. Applying a face mask to the client if outside the client room
e. Inserting an indwelling urinary catheter to prevent skin breakdown

425. A client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic
hormone (SIADH) as a complication of the cancer. Besides treatment of lung cancer, the nurse
anticipates which interventions may be prescribed to treat the SIADH? Select all that apply.
a. Increase fluid intake
b. Decreased sodium intake
c. Institute safety measures
d. Frequent monitoring of sodium blood levels
e. Gather data about the neurological status frequently
f. Medication that is antagonistic to antidiuretic hormone

426. The client is admitted to the hospital with a diagnosis of suspected Hodgkin's Disease. Which
signs and symptoms of the client associated with Hodgkin's Disease? Select all that apply.
a. Fatigue
b. Weakness
c. Joint pain
d. Weight gain
e. Night sweats
f. Enlarged lymph nodes

427. When reinforcing teaching about signs and symptoms of ovarian cancer with a community
group of women, the nurse emphasizes which sign / symptom as being a typical manifestation of the
disease recognized by persons diagnosed with the condition?
a. Pelvic cramping
b. Sharp abdominal pain
c. Abdominal distension or fullness
d. Postmenopausal vaginal bleeding

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428. The nurse is caring for a client after a mastectomy. Which finding would indicate that the
client is experiencing a complication that may become a chronic problem related to the surgery?
a. Pain at the incisional site
b. Arm edema on the operative side
c. Sanguineous drainage in the Jackson Pratt drain
d. Complaints of decreased sensation near the operative site

429. The nurse is reinforcing discharge instructions to a client with cancer of the prostate after a
suprapubic prostatectomy. the nurse should reinforce which discharge instruction? Select all that
apply
a. Avoid driving a car for one week
b. Restrict fluid intake to prevent incontinence
c. Take the prescribed stool softener everyday
d. Avoid lifting objects heavier than 20 pounds for 6 weeks
e. Inspect the incision of the scrotum every day for any redness
f. Notify the primary health care provider if small blood clots are noticed during urination

430. The nurse is reviewing the laboratory results of a client who is receiving chemotherapy and
notes that the platelet count is 10000 mm3. On the basis of this laboratory value, the nurse should
perform which intervention? Select all that apply
a. Monitor stools for occult blood
b. Keep away from persons who have colds or feel ill
c. Instruct the client not to bend over at the waist or lift
d. Floss teeth and rinse mouth with mouthwash after every meal
e. Instruct the client to blow nose very gently without blocking either nostril

431. The nurse is caring for a client who is receiving an IV infusion of an antineoplastic
medication. During the infusion, the client complains of pain at the insertion site. During an
inspection of the site, the nurse notes redness and swelling. The nurse should take which appropriate
action?
a. Notify the RN immediately
b. Administer pain medication to reduce the discomfort
c. Apply ice and maintain the infusion rate, as prescribed
d. Elevate the extremity of the IV site, and slow the infusion

432. The client with squamous cell carcinoma of the larynx is receiving bleomycin intravenously.
The nurse caring for the client anticipates that which diagnostic study will be prescribed? Select all
that apply
a. Chest x-ray
b. Echocardiography
c. Electrocardiography
d. Cervical radiographs
e. Pulmonary function studies

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433. The client with acute myelocytic leukaemia is being treated with busulfan. Which laboratory
value should the nurse specifically monitor during treatment with this medication?
a. Clotting time
b. Uric acid level
c. Potassium level
d. Blood glucose level

434. The nurse is assisting with caring for a client with cancer who is receiving cisplatin. Which
adverse effects are associated with this medication? Select all that apply
a. Tinnitus
b. Ototoxicity
c. Hyperkalemia
d. Hypercalcemia
e. Nephrotoxicity
f. Hypomagnesemia

435. The licensed practical nurse is assisting the registered nurse to create a teaching plan for the
client receiving an antineoplastic medication. The LPN expects which information to be included?
Select all that apply
a. Rinse mouth after meals and use a soft toothbrush
b. Notify the primary health care provider if the temperature is above 101
c. Maintain oral hygiene and inspect the mouth for sores daily
d. A sore throat is expected so the client should suck on soothing throat lozenges
e. Consult with the primary health care provider before receiving immunization

436. The client with ovarian cancer is being treated with vincristine. The nurse monitors the client,
knowing which adverse effect is specific to this medication?
a. Diarrhea
b. Hair loss
c. Chest pain
d. Extremity numbness

437. The nurse is reviewing the history and physical examination of a client who is receiving
asparaginase, in Antineoplastic agent. The nurse consults with a registered nurse regarding the
administration of the medication if which is documented in the client's history?
a. Pancreatitis
b. Diabetes mellitus
c. Myocardial infarction
d. Chronic obstructive pulmonary disease

438. Tamoxifen is prescribed for a client with metastatic breast carcinoma. The nurse understands
that which is the primary action of this medication?
a. Increase DNA and RNA synthesis
b. Promote the biosynthesis of nucleic acid
c. Increase estrogen concentration and estrogen response
d. Complete with estradiol for binding to estrogen in tissue containing high concentrations of
receptor

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439. The client with metastatic breast cancer is receiving tamoxifen. The nurse specifically
monitors which laboratory value while the client is taking this medication?
a. Glucose level
b. Calcium level
c. Potassium level
d. Prothrombin time

440. The client with small cell lung cancer is being treated with etoposide and the nurse is
assisting with caring for the client during Administration. The client gets up to use the bathroom and
is dizzy and very weak. The nurse understands that these symptoms are likely as a result of which
side/adverse effect that is specifically associated with this medication?
a. Alopecia
b. Chest pain
c. Pulmonary fibrosis
d. Orthostatic hypotension

441. The nurse is caring for a client after thyroidectomy and notes that calcium gluconate is
prescribed. The nurse determines that this medication has been prescribed for which reason?
a. Treat thyroid storm
b. Prevent cardiac irritability
c. Treat hypocalcemic tetany
d. Stimulate the release of parathyroid hormone

442. The nurse is collecting data regarding a client after thyroidectomy and knows the
development of a horse and weak voice. Which nursing action is appropriate?
a. Check for signs of bleeding
b. Administer calcium gluconate
c. Notify the RN immediately
d. Reassure the client that this is usually a temporary condition

443. A client is admitted to the emergency department, and a diagnosis of myxedema coma is
made. Which action should the nurse prepare to carry out initially?
a. Warm the client
b. Maintain a patent Airway
c. Monitor intravenous fluid
d. Administer thyroid hormone

444. The nurse is assisting with preparing a teaching plan for the client with diabetes mellitus
regarding proper foot care. Which instruction should be included in the plan of care?
a. Soak the feet in hot water
b. Avoid using soap to wash the feet
c. Applying moisturizing lotion to dry feet, but not between the toes
d. Always have a podiatrist cut your toenails, never cut them yourself

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445. The nurse provides dietary instructions to a client with diabetes mellitus regarding the
prescribed diabetic diet. Which statement made by the client indicates the need for further teaching?
a. I'll eat a balanced meal plan
b. I need to drink diet soft drinks
c. I need to buy special dietetic foods
d. I will snack on fruit instead of cake

446. A client who has been newly diagnosed with diabetes mellitus has been stabilized with daily
insulin injections. Which teaching information should the nurse reinforce upon discharge?
a. Keep insulin vials refrigerated at all time
b. Rotate the insulin injection sites systematically
c. Increase amount of insulin before unusual exercise
d. Monitor the urine acetone level to determine the insulin dosage

447. The nurse reinforces teaching to a client with diabetes mellitus regarding differentiating
between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching
by stating that glucose will be taken if which symptom develops?
a. Polyuria
b. Shakiness
c. Blurred vision
d. Fruity breath odour

448. When the nurse is reinforcing instructions to a client who has been newly diagnosed with
type 1 diabetes mellitus, which statement by the client would indicate that teaching has been
effective?
a. I will stop taking my insulin if I'm too sick to eat
b. I will decrease my insulin dose during times of illness
c. I will dress my insulin dose according to the level of glucose in my urine
d. I will notify my primary health care provider if my blood glucose level is consistently greater
than 250

449. The nurse is monitoring a client who has been newly diagnosed with diabetes mellitus for
signs of complications. Which statement made by the client would indicate hiperglicemia and thus
warrant primary health care provider notification?
a. I am urinating a lot
b. My pulse is really slow
c. I'm sweating for no reason
d. My blood pressure is really high

450. The nurse is reinforcing instructions to a client with diabetes mellitus who is recovering from
diabetic ketoacidosis regarding measures to prevent a recurrence. Which instruction is important for
the nurse to emphasize?
a. Eat six small meals daily
b. Test the urine Ketone level
c. Monitor blood glucose level frequently
d. Receive appropriate follow-up care

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451. The nurse is reinforcing discharge teaching to a client who has Cushing's syndrome. Which
statement made by the client indicates that the instructions related to dietary management were
understood?
a. I can eat foods that contain potassium
b. I will need to limit the amount of protein in my diet
c. I'm fortunate that I can eat all the salty foods I enjoy
d. I am fortunate that I do not need to follow any special diet

452. The nurse educator asks the nursing student ever called a science / symptoms of
hypothyroidism. The nurse educator determines that the student understands this disorder if which
are included in the student's response? Select all that apply
a. Dry skin
b. Irritability
c. Palpitations
d. Weight loss
e. Constipation
f. Cold intolerance

453. A nurse is caring for a postoperative parathyroidectomy client. Which would require the
nurses immediate attention?
a. Incisional pain
b. Laryngeal stridor
c. Difficulty voiding
d. Abdominal cramp

454. The nurse notes that a client with type 1 diabetes mellitus has a lipodystrophy on both upper
thighs. Which further information should the nurse obtain from the client during data collection?
a. Plan for injection rotation
b. Consistency of aspiration
c. Preparation of the injection site
d. Angle at which the medication is administered

455. A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of
hypoglycemia. Which statement by the client indicates a correct understanding of Humulin n insulin
and exercise?
a. I should not exercise after lunch
b. I should not exercise after breakfast
c. I should not exercise in the late evening
d. I should not exercise in the late afternoon

456. The nurse is reinforcing teaching for a client regarding how to mix regular insulin and NPH
insulin in the same syringe. Which action performed by the client indicates the need for further
teaching?
a. Withdrawals the NPH insulin first
b. Withdraws the regular insulin first
c. Inject air into NPH insulin vial first

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 d. Injection amount of equal air to the desired dose of insulin into the vial
457. The home care nurse visits a client who was recently diagnosed with diabetes mellitus who is
taking Humulin NPH insulin daily. The client asks the nurse how to store the unopened vials of
insulin. The nurse should provide which information?
a. Freeze the insulin
b. Refrigerate the insulin
c. Store the insulin in a dark, dry place
d. Keep the insulin at room temperature

458. The home care nurse is visiting a client who was recently diagnosed with type 2 diabetes
mellitus. The client, prescribed repaglinide and Metformin, asks the nurse to explain these
medications. The nurse should reinforce which instructions to the client? Select all that apply
a. Diarrhea can occur secondary to metformin
b. The repaglinide is not taken if a meal is skipped
c. The repaglinide is taken 30 minutes before eating
d. Candy or other simple sugar is carried and used to treat mild hypoglycemia episodes
e. Muscle pain is an expected side effect of metformin and may be treated with acetaminophen
f. Metformin increases hepatic glucose production to prevent hypoglycemia associated with
repaglinide

459. The nurse is monitoring a client receiving Levothyroxine Sodium for hypothyroidism. Which
findings indicate the presence of a side effect associated with this medication? Select all that apply
a. Insomnia
b. Weight loss
c. Bradycardia
d. Constipation
e. Mild heat intolerance

460. The primary healthcare provider prescribes exenatide for a client with type 1 diabetes
mellitus who takes insulin. The nurse knows that which is the most appropriate intervention?
a. This medication is administered within 60 minutes before the morning and evening meal
b. The medication is withheld and the primary health care provider is called to question the
prescription for the client
c. The client is monitored for GI side effects after administration of the medication
d. The insulin is withdrawn from the penlet into an insulin syringe to prepare for administration

461. A client is taking Humulin NPH insulin daily every morning. The nurse reinforces
instructions to the client and should tell the client that which is the most likely time for a
hypoglycemic reaction to occur?
a. 2 to 4 hours after Administration
b. 6 to 14 hours after Administration
c. 16 to 18 hours after Administration
d. 18 to 24 hours after Administration

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462. A client with diabetes mellitus visited a Health Care Clinic. The clients diabetes mellitus
previously had been well controlled with Glyburide daily, but recently the fasting blood glucose
level has been 180 mg/dL to 200 mg/dL. Which medication, added to the clients regimen, may have
contributed to the hyperglycemia?
a. Atenolol
b. Prednisone
c. Phenelzine
d. Allopurinol

463. The home care nurse visits a client at home who has been prescribed prednisone 5 mg orally
daily. The nurse reinforces teaching for the client about the medication. Which statement made by
the client indicates a need for further teaching?
a. I can take aspirin or my antihistamine if I need it
b. I need to take the medications everyday at the same time
c. I need to avoid coffee, tea, Cola, and chocolate in my diet
d. If I gain more than 5 pounds a week, I will call my doctor

464. Desmopressin acetate is prescribed for the treatment of diabetes insipidus. The nurse
monitors the client after medication administration for which therapeutic response?
a. Decreased urinary output
b. Decreased blood pressure
c. Decreased peripheral edema
d. Decreased blood glucose level

465. Glimepiride is prescribed for a client with diabetes mellitus. The nurse reinforces instructions
for the client and tells the client to avoid which while taking this medication?
a. Alcohol
b. Organ Meats
c. Whole grain cereal
d. Carbonated beverages

466. The nurse is reinforcing teaching to a client about enough Colonoscopy procedure. The nurse
should include in the instructions that the client will be placed in which position for the procedure
a. Left Sims position
b. Lithotomy position
c. Knee to chest position
d. Right Sims position

467. The nurse is preparing to perform an abdominal examination which Step should be taken
first?
a. Palpation
b. Inspection
c. Percussion
d. Auscultation

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468. The nurse reinforces postoperative liver biopsy instructions to a client. Which should the
nurse tell the client?
a. Avoid alcohol for 8 hours
b. Remain NPO for 24 hours
c. Lie on the right side for 2 hours
d. Save all stools to be checked for blood

469. The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse anticipates that
the client is at risk for which vitamin deficiency?
a. Vitamin A
b. Vitamin C
c. Vitamin E
d. Vitamin B12

470. The nurse is caring for a client after a billroth II (gastrojejunostomy) procedure. During
review of the postoperative prescriptions, what should the nurse clarify?
a. Leg exercises
b. Early ambulation
c. Irrigating NG Tube
d. Coughing and deep breathing exercise

471. The nurse is reinforcing discharge instructions to a client after a gastrectomy. Which measure
should the nurse include during client teaching to help prevent dumping syndrome?
a. Ambulate after a meal
b. Eat High carbohydrate Foods
c. Limit the fluids taken with meals
d. Sit in a High Fowler's position during meals

472. The nurse is monitoring a client for the early signs and symptoms of dumping syndrome.
Which indicates this occurrence?
a. Sweating and pallor
b. Dry skin and stomach pain
c. Bradycardia and indigestion
d. Double vision and chest pain

473. The nurse is reviewing the record of a client with crohn's disease. Which dual characteristics
should the nurse expect to see documented in the record?
a. Diarrhea
b. Constipation
c. Bloody stools
d. Stool constantly oozing from the rectum

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474. A client with ascites is scheduled for a paracentesis. The nurse is assisting the primary health
care provider with performing the procedure. Which position should the nurse assess the client into
for this procedure?
a. Flat
b. Upright
c. Left side lying
d. Right side lying

475. The nurse is reviewing the prescriptions of a client admitted to the hospital with a diagnosis
of acute pancreatitis. Which intervention should the nurse expect to be prescribed? Select all that
apply
a. Administer antacids, as prescribed
b. Encourage coughing and deep breathing
c. Administer anticholinergics, as prescribed
d. Maintain the client in a supine and flat position
e. Encourage small, frequent, high calorie feeding

476. It has been determined that a client with hepatitis has contracted the infection from
contaminated food. Which type of hepatitis is the client most likely experiencing?
a. Hepatitis A
b. Hepatitis B
c. Hepatitis C
d. Hepatitis D

477. The nurse is reviewing the Primary Health Care provider's prescriptions written for a client
admitted with acute pancreatitis. Which PHCP prescription should the nurse verify if noted in the
client's chart?
a. NPO status
b. An anticholinergic medication
c. Position the client Supine and flat
d. Prepare to insert a nasogastric tube

478. A client with a hiatal hernia chronically experiences heartburn after meals. Which should the
nurse teach the client to avoid?
a. Lying recumbent after meals
b. Eating small, frequent, Bland meals
c. Raising the head of the bed on 6-inch blocks
d. Taking histamine receptor antagonist medication, as prescribed

479. The nurse is monitoring for stoma prolapse in a client with a colostomy. Which stoma
observation should indicate that a prolapse has occurred?
a. Dark and bluish
b. Sunken and hidden
c. Narrowed and flattened
d. Protruding and swollen

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480. An ultrasound of the gallbladder is scheduled for the client with a suspected diagnosis of
cholecystitis. What should the nurse explain to the client about this test?
a. The test is uncomfortable
b. The test requires that the client be NPO
c. The test requires the client to lie still for short intervals
d. The test is preceded by the administration of oral tablets

481. A client with crohn's disease is scheduled to receive an infusion of infliximab. The nurse
assisting with caring for the client should take which action to monitor the effectiveness of
treatment?
a. Monitoring the leukocyte count for 2 days after the infusion
b. Checking the frequency and consistency of bowel movements
c. Checking to serum liver enzyme levels before and after the infusion
d. Carrying out a hematest on gastric fluids after the infusion is completed

482. The client has an as-needed prescription for loperamide hydrochloride. For which condition
should the nurse administer this medication?
a. Constipation
b. Abdominal pain
c. An episode of diarrhea
d. Hema-test positive nasogastric tube drainage

483. The client has an as-needed prescription for ondansetron. For which condition should the
nurse administer this medication?
a. Paralytic Ileus
b. Incisional pain
c. Urinary retention
d. Nausea and vomiting

484. The client has begun medication therapy with pancrelipase. The nurse evaluates that the
medication is having the optimal intended benefit if which effect is observed?
a. Weight loss
b. Relief of heartburn
c. Reduction of steatorrhea
d. Absence of abdominal pain

485. An older client has recently been taking cimetidine. The nurse should monitor the client for
which most frequent central nervous system side effect of this medication?
a. Tremors
b. Dizziness
c. Confusion
d. Hallucinations

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486. A histamine2 receptor antagonist will be prescribed for a client. The nurse understands that
which medications are H2 receptor antagonist? Select all that apply
a. Nizatidine
b. Ranitidine
c. Famotidine
d. Cimetidine
e. Esomeprazole
f. Lansoprazole

487. The client who frequently uses non-steroidal anti-inflammatory drugs has been taking
misoprostol. The nurse determines that this medication is having the intended therapeutic effect if
which is noted?
a. Results diarrhea
b. Relief of epigastric pain
c. Decreased platelet count
d. Decreased white blood cell count

488. The client has been taking omeprazole for 4 weeks. The nurse evaluates that the client is
receiving the optimal intended effect of the medication if the client reports the absence of which
symptom?
a. Diarrhea
b. Heartburn
c. Flatulence
d. Constipation

489. A client with a peptic ulcer is diagnosed with a helicobacter pylori infection. The nurse is
reinforcing teaching for the client about the medications prescribed, including Clarithromycin,
esomeprazol, and Amoxicillin. Which statement by the client indicates the best understanding of the
medication regimen?
a. My ulcer will heal because these medications will kill the bacteria
b. These medications are only taken when I have pain from my ulcer
c. These medications will kill the bacteria and stop the acid production
d. These medications will coat the ulcer and decrease the acid production in my stomach

490. The client with a gastric ulcer has a prescription for sucralfate 1g by mouth four times daily.
The nurse should schedule the medication to be administered at which times?
a. With meals and at bedtime
b. Every 6 hours around the clock
c. One hour after meals and at bedtime
d. One hour before meals and at bedtime

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491. The nurse is reinforcing instructions to a hospitalized client with a diagnosis of emphysema
about positions that will enhance the effectiveness of breathing during dyspneic episodes. Which
position should the nurse instruct the client to assume?
a. Side lying in bed
b. Sitting in a recliner chair
c. Sitting up in bed at a 90 degree angle
d. Sitting on the side of the bed leaving on an overbed table

492. The nurse is gathering data on a client with a diagnosis of tuberculosis. The nurse should
review the results of which diagnostic test to confirm this diagnosis?
a. Chest x-ray
b. Bronchoscopy
c. Sputum culture
d. Tuberculin skin test

493. The nurse is caring for a client after a bronchoscopy and biopsy. Which finding should be
reported immediately to the primary health care provider?
a. Dry cough
b. Hematuria
c. Bronchospasm
d. Blood-tinged sputum

494. The nurse is preparing a list of home care instructions for the client who has been
hospitalized and treated for tuberculosis. Which instruction should the nurse reinforce? Select all that
apply
a. Activity should be resumed gradually
b. Avoid contact with other individuals except family members for at least 6 months
c. A sputum culture is needed every two to four weeks once medication therapy is initiated
d. Respiratory isolation is not necessary because family members have already been exposed
e. Cover the nose and mouth when coughing or sneezing and confine used tissues to plastic
bags
f. When one sputum culture is negative, the client is no longer considered infectious and can
usually return to his or her former employment

495. The nurse is instructing a client about pursed lip breathing, and the client asks the nurse about
its purpose. The nurse should tell the client that the primary purpose of pursed lip breathing is
which?
a. Promote oxygen intake
b. Strengthen the diaphragm
c. Strengthen the intercostal muscles
d. Promote carbon dioxide elimination

496. The low pressure alarm sounds on the ventilator. The nurse checks the client and then
attempts to determine the cause of the alarm but is unsuccessful. Which initial action should the
nurse take?
a. Administer oxygen
b. Ventilates the client manually

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 c. Check the client vital signs
d. Start CPR

497. The nurse is assigned to care for a client after a left pneumonectomy. Which position is
contraindicated for this client?
a. Lateral position
b. Low Fowler's position
c. Semi Fowler's position
d. Head of the bed elevated at 40 degrees

498. The nurse is caring for a client after a pulmonary angiography via catheter insertion into the
left groin. The nurse monitors for an allergic reaction to the contrast medium by observing for the
presence of which?
a. Hypothermia
b. Respiratory distress
c. Hematoma in the left groin
d. Discomfort in the left groin

499. The nurse is reinforcing discharge instructions to the client with pulmonary sarcoidosis. The
nurse knows that the client understands the information if the client verbalizes which early sign of
exacerbation?
a. Fever
b. Fatigue
c. Weight loss
d. Shortness of breath

500. The nurse is caring for several clients with respiratory disorders. Which client is at least risk
for developing a Tuberculosis infection?
a. An uninsured man who is homeless
b. A woman newly immigrated from Korea
c. A man who is inspector for the US Postal Service
d. An older woman admitted from a long-term care facility

501. The client is diagnosed with pleurisy. The nurse should expect to see which signs and
symptoms? Select all that apply
a. Pleural friction rub
b. Sharp, knife like pain
c. Cyanosis of the lips and nail beds
d. Pain that occurs on both sides of the chest
e. Pain occurs most often during inspiration

502. The nurse knows that a hospitalized client has experienced a positive reaction to the
tuberculin skin test. Which action by the nurse is priority?
a. Report the findings
b. Document the finding in the client's record
c. Call the employee health service department
d. Call the radiology department for a chest x-ray

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503. A client being discharged from the hospital to home with a diagnosis of tuberculosis is
worried about the possibility of infecting family members and others. Which information should
reassure the client that contaminating family members and others is not likely?
a. The family does not need therapy, and the client will not be contagious after one month of
medication therapy
b. The family does not need therapy, and the client will not be contagious after six consecutive
weeks of medication therapy
c. The family will receive prophylactic therapy, and the client will not be contagious after one
continuous week of medication therapy
d. The family will receive prophylactic therapy, and the client will not be contagious after two
to three consecutive weeks of medication therapy

504. The nurse is reinforcing discharge teaching to a client diagnosed with tuberculosis who has
been taking medication for 1 and 1/2 Weeks. The nurse knows that the client has understood the
information if which statement is made?
a. I can't shop at the mall for the next 6 months
b. I need to continue medication therapy for 2 months
c. I can return to work if a sputum culture comes back negative
d. I should not be contagious after two to three weeks of medication therapy

505. The nurse is caring for a client with emphysema receiving oxygen. The nurse should consult
with the registered nurse at the oxygen flow rate exceeding how many litres/minute of oxygen?
a. 1 L/min
b. 2 L/min
c. 6 L/min
d. 10 L/min

506. Rifabutin is prescribed for a client with an active mycobacterium avium complex disease and
tuberculosis the nurse should monitor for which side / adverse effects of the medication? Select all
that apply.
a. Signs of hepatitis
b. Flu-like syndrome
c. Low neutrophil count
d. Vitamin B6 deficiency
e. Ocular pain or blurred vision
f. Tingling and numbness of the fingers

507. A client has a prescription to take guaifenesin every 4 hours, as needed. The nurse determines
that the client understands the most effective use of this medication if the client makes which
statement?
a. I will watch for irritability as a side effect
b. I will take the tablet with a full glass of water
c. I will take an extra dose if the cough is accompanied by a fever
d. I will crush the sustained release tablet if immediate relief is needed

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508. A postoperative client has received a dose of naloxone hydrochloride for respiratory
depression shortly after transfer to the nursing unit from the post-anesthesia Care Unit. After
administration of the medication, the nurse should check the client for which sign/ symptom?
a. pupillary changes
b. scattered lung wheezes
c. sudden increase in pain
d. sudden episodes of diarrhea

509. A client has been taking isoniazid for 2 months. The client complains to the nurse about
numbness, paresthesia, and tingling in the extremities. The nurse interprets that the client is
experiencing which problem?
a. Hypercalcemia
b. peripheral neuritis
c. small blood vessel spasm
d. impaired peripheral circulation

510. A client is to begin a 6-month course of therapy with isoniazid. The nurse should plan to
provide which information to the client?
a. drink alcohol in small amounts only
b. report yellow eyes or skin immediately
c. increase intake of Swiss or aged cheeses
d. avoid vitamin supplements during therapy

511. My client has been started on long-term therapy with Rifampin. Which information about this
Medication should the nurse provide to the client?
a. Should always be taken with food or antacids
b. should be double dosed if one dose is forgotten
c. causes red orange discoloration of sweat, tears, urine and feces
d. maybe discontinued independently if symptoms are gone in 3 months

512. The nurse is giving a client taking ethambutol information about the medication. The nurse
determines that the client understands the instructions to the client to report which occurrence
immediately?
a. impaired sense of hearing
b. problems with visual acuity
c. gastrointestinal side effects
d. red orange discoloration of body secretions

513. Cycloserine is out of the medication regimen for a client with tuberculosis. Which instruction
should the nurse reinforce in the client teaching plan regarding this medication?
a. to take the medication before meals
b. to return the clinic weekly for serum drug level testing
c. it is not necessary to restrict alcohol intake with this medication
d. it is not necessary to call the primary health care provider if a skin rash occurs

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514. A client with tuberculosis is being started on anti-tuberculosis therapy with isoniazid. Before
giving the client the first dose, the nurse ensures that which Baseline study has been completed?
a. electrolyte levels
b. coagulation time
c. liver enzyme levels
d. serum creatinine level

515. A client is receiving acetylcysteine 20% solution diluted in 0.9% normal saline by nebulizer.
The nurse should have which item available for a possible adverse event after giving this
medication?
a. Ambu bag
b. Intubation Tray
c. nasogastric tube
d. suction equipment

516. A post cardiac surgery client with a blood urea nitrogen level of 45 mg/dL (16.2 mmol/L) in
a serum creatinine level of 2.2 mg/dL (193.6 mcmol/L) has a total 2 hour urine output of 25 ml. The
nurse understands that the client is at risk for which condition?
a. Hypovolemia
b. Acute kidney injury
c. Glomerulonephritis
d. Urinary tract infection

517. The nurse is preparing to ambulate a postoperative client after cardiac surgery. The nurse
plans to do which to enable the client to best tolerate the ambulation?
a. provide the client with a walker
b. remove the telemetry equipment
c. encourage the client to cough and deep breathe
d. premedicate the client with an analgesic before ambulating

518. The client is wearing a continuous cardiac monitor which begins to alarm at the nurses
station. The nurse sees no electrocardiographic complexes on the screen. The nurse should do which
action first?
a. Call a code blue
b. check the client status and lead placement
c. call the primary health care provider
d. press the recorder button on the ECG console

519. The nurse in the medical unit is caring for a client with heart failure. The client suddenly
develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema.
The nurse immediately notifies the registered nurse and expects which interventions to be
prescribed?
a. administering oxygen
b. inserting a Foley catheter
c. administering Furosemide
d. administering morphine sulphate intravenously
e. transferring the client to the coronary Care Unit

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 f. placing the client in a low Fowler's side-lying position
520. The nurse is caring for a client on a cardiac monitor who is alone in a room at the end of the
hall. The client has a short bursts of ventricular tachycardia, followed by ventricular fibrillation. The
client suddenly loses Consciousness. Which intervention should the nurse do first
a. go to the nurse's station quickly and call a code
b. run to get a defibrillator from an adjacent nursing unit
c. call for help initiate cardiopulmonary resuscitation
d. start Oxygen by cannula at 10L/minute in lower the head of the bed

521. The nurse is monitoring a client following cardioversion. Which observations should be of
highest priority to the nurse?
a. blood pressure
b. status of Airway
c. Oxygen flow rate
d. level of level of car

522. To use an external cardiac defibrillator on a client which action should be performed to check
the cardiac rhythm?
a. holding the defibrillator paddles firmly against the chest
b. applying adhesive patch electrodes to the skin the moving away from the client
c. applying standard electrocardiographic monitoring leads to the client in observing the
Rhythm
d. connecting Standard Electric cardiographic electrodes to a transtelephonic monitoring device

523. The nurse is assisting with caring for the client immediately after insertion of a permanent
demand pacemaker via the right subclavian vein. The nurse prevents dislodgement of the piece in the
catheter by implementing which intervention?
a. Limiting movement in Abduction of the left arm
b. Limited movement in Abduction of the right arm
c. Assisting the client to get out of bed and ambulate with a walker
d. Having a physical therapist do active range of motion to the right arm

524. A client diagnosed with thrombophlebitis one day ago suddenly complains of chest pain and
shortness of breath, and the client is visibly anxious. Which is a life-threatening complication that
could be occurring?
a. Pneumonia
b. Pulmonary edema
c. Pulmonary embolism
d. Myocardial infarction

525. a 24 year old man seeks medical attention for complaints of claudication in the arch of the
foot. The nurse also notes superficial thrombophlebitis of the lower leg. Next the nurse should check
the client's medical history for which item?
a. smoking history
b. recent exposure to allergens
c. history of recent insect bites
d. family tendency toward peripheral vascular disease

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526. a nurse has reinforced instructions to the client with Raynaud's disease about self-
management of the disease process. The nurse determines that the client needs further teaching if the
client makes which statement?
a. Smoking cessation is very important
b. moving to a warmer climate should help
c. Sources of caffeine should be eliminated from the diet
d. taking nifedipine as prescribed will decrease muscle spasm

527. A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger,
and begins coughing frothy pink tinged sputum. The nurse wasn't surprised and is expecting to hear
which breath sounds bilaterally?
a. Rhonchi
b. Crackles
c. Wheezing
d. Diminished breath sounds

528. The nurse is collecting data on a client with a diagnosis of right sided heart failure. The nurse
should expect to know which specific characteristic of this condition?
a. Dyspnea
b. Hacking cough
c. Dependant edema
d. Crackles on lung auscultation

529. The nurse is checking the neurovascular status of a client who returned to the surgical nursing
unit 4 hours ago, after undergoing an aortoiliac bypass graft. The affected leg is warm in the nurse
notes redness and edema. The pedal pulses palpable and unchanged from a mission. Based on this
data, the nurse should make which determination about the client's neurovascular status?
a. moderately impaired in the surgeon should be called
b. normal, caused by increased blood flow through the leg
c. slightly deteriorating, and should be monitored for another hour
d. how to quit from an arterial approach, but Venus complications are arising

530. The primary health care provider is going to perform carotid massage on a client with a rapid
rate atrial fibrillation. Which intervention should the nurse anticipate? Select all that apply.
a. The client should be placed on a cardiac monitor
b. The primary health care provider massages to carotid artery for a full minute
c. The head should be turned toward the side to be massaged
d. Rhythm strips should be obtained before during and after the procedure
e. Monitor the vital signs, cardiac Rhythm and level of Consciousness after the procedure

531. The nurse reinforces discharge instructions to a postoperative client who is taking Warfarin
sodium. Which statement made by the client reflects the need for further teaching?
a. I will take my pills everyday at the same time
b. I will be certain to avoid alcohol consumption
c. I I have already called my family to pick up a MedicAlert bracelet
d. I will take enteric-coated aspirin for my headaches because it is coated

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532. A client is receiving digoxin daily. The nurse suspects digoxin toxicity after noting which
signs and symptoms? Select all that apply
a. Visual disturbances
b. Nausea and vomiting
c. Apical pulse rate of 63 beats per minute
d. Serum digoxin level of 2.3 ng/ mL (2.93 nmol/L)
e. Serum potassium level of 3.9 mEq/L (3.9 mmol/L)

533. Heparin sodium is prescribed for the client. Which laboratory result indicates that Heparin is
prescribed at a therapeutic level?
a. thrombocyte count of 100,000 mm3
b. Prothrombin time (PT) of 21 seconds
c. International normalized ratio (INR) of 2.3
d. activated partial thromboplastin time (aPTT) of 55 seconds

534. The nurse is monitoring a client who is taking propranolol. Which data collection finding
would indicate a potential serious complication associated with propranolol?
a. The development of complaints of insomnia
b. The development of audible expiratory wheezes
c. A baseline resting heart rate of 88 beats per minute followed by a resting heart rate of 72
beats per minute after 2 doses of the medication
d. A baseline blood pressure of 150 / 80 mm Hg followed by a blood pressure of 138 / 72 mm
Hg after two doses of the medication

535. Isosorbide mononitrate is prescribed for a client with angina pectoris. The client tells the
nurse that the medication is causing a chronic headache. Which action should the nurse suggest to
the client?
a. cut the dose in half
b. discontinue the medication
c. take the medication with food
d. contact the primary health care provider

536. A client is diagnosed with an acute myocardial infarction and is receiving tissue plasminogen
activator, alteplase. Which is the priority nursing intervention?
a. Monitor for kidney failure
b. Monitor psychosocial status
c. Monitor for signs of bleeding
d. Have Heparin sodium available

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537. The hospitalized client with coronary artery disease complaints of substernal chest pain. After
checking the client's heart rate and blood pressure the nurse administers nitroglycerin, 0.4 mg,
sublingually. After 5 minutes the client states, “ my chest still hurts.” which appropriate actions
should the nurse take? Select all that apply.
a. Call a code blue
b. Contact the client's family
c. Check the client's pain level
d. Check the client's blood pressure
e. Administer a second nitroglycerin, 0.4 mg sublingually

538. The home health care nurse is visiting a client with elevated triglyceride levels in a serum
cholesterol level of 398 mg/dL (9.95 mmol/L). The client is taking cholestyramine. Which statement
made by the client indicates the need for further Health teaching?
a. Constipation and bloating might be a problem
b. I'll continue to watch my diet and reduce my fats
c. Walking a mile each day will help the whole process
d. I'll continue my nicotinic acid from the health food store

539. A client is taking nicotinic acid for hyperlipidemia, and the nurse reinforces instructions to
the client about the medication. Which statement by the client indicates an understanding of the
instructions?
a. it is not necessary to avoid the use of alcohol
b. the medication should be taken with meals to decrease Flushing
c. clay-colored stools are a common side-effect and should not be of concern
d. ibuprofen taken 30 minutes before the nicotinic acid should decrease the Flushing

540. The nurse is planning to administer Hydrochlorothiazide to a client. Which are concerns
related to the administration of this medication?
a. hyperuricemia, hyperkalemia
b. hypokalemia, hyperglycemia, Sulfa allergy
c. hypokalemia, increase risk of osteoporosis
d. hyperkalemia, hypoglycemia, penicillin allergy

541. The nurse is caring for a client with epididymitis. Which treatment modalities should be
implemented? Select all that apply
a. Bed rest
b. Sitz bath
c. Antibiotics
d. Heating pad
e. Scrotal elevation

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542. a client has epididymitis as a complication of a urinary tract infection. The nurse is giving
the client instructions to prevent recurrence. The nurse determines that the client needs further
teaching if the client states the intention to do which action?
a. drinking increased amount of fluids
b. limit the force of the stream during voiding
c. continue to take antibiotics until all symptoms are gone
d. used condoms to eliminate the risk associated with chlamydia and gonorrhea

543. The nurse is collecting data from a client who had benign prostatic hyperplasia (BPH) in the
past. To determine whether the client is currently experiencing exacerbation of BPH, the nurse
should ask the client about the presence of which early symptom?
a. Nocturia
b. Urinary retention
c. Urge incontinence
d. Decrease force in the Stream of urine

544. The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse
tells the client that it is important to maintain the prescribed well time for the dialysis because of the
risk of which complication?
a. Peritonitis
b. Hyperglycemia
c. Hyperphosphatemia
d. Disequilibrium syndrome

545. a client with chronic kidney disease has been on dialysis for 3 years. The client is receiving
the usual combination of medications for the disease, including the aluminum hydroxide as a
phosphate binding agent. The client now has mental cloudiness, dementia and complaints of bone
pain which does this data indicate?
a. advancing uremia
b. phosphate overdose
c. folic acid deficiency
d. aluminum intoxication

546. A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse
monitors the client for which Signs by symptoms of this disorder?
a. edema and purpura of the left
b. warmth, redness, and pain in the left hand
c. aching pain, pallor, and edema of the left arm
d. pallor, diminished pulse, and pain in the left hand

547. The nurse is reviewing the medical record of a client with a diagnosis of pyelonephritis.
Which disorder noted on the client's record should the nurse identify as a risk factor for this
diagnosis?
a. Hypoglycemia
b. Diabetes mellitus
c. Coronary artery disease
d. Orthostatic hypotension

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548. The nurse is reviewing the client's record and notes that the primary health care provider has
documented the client has a renal disorder. Which laboratory results would indicate a decrease in
renal function? select all that apply.
a. Elevated serum creatinine level
b. Elevated thrombocyte count
c. Decrease red blood cell count
d. Decrease white blood cell count
e. Elevated blood urea nitrogen level

549. a client is scheduled for intravenous pyelography (IVP). Which priority nursing action should
the nurse take?
a. Restrict fluids
b. Administer a sedative
c. Determine if there's a history of allergies
d. Administer an oral preparation of radiopaque dye

550. After a renal biopsy, the client complains of pain at the biopsy site that radiates to the front of
the abdomen. Which would this indicate?
a. Bleeding
b. Infection
c. Renal colic
d. Normal expected pain

551. The nurse is monitoring a client receiving peritoneal dialysis notes that the client outflow is
less than the envelope. The nurse should take which action? Select all that apply.
a. Contact the nephrologist
b. Check the level of the drainage bag
c. Reposition the client to his or her side
d. Place the client in good body alignment
e. Check the peritoneal dialysis system for Kinks
f. Increase the flow rate of the peritoneal dialysis solution

552. a male client has a tentative diagnosis of urethritis. The nurse should assess the client for
which manifestation of the disorder?
a. hematuria and pyuria
b. dysuria and proteinuria
c. hematuria and urgency
d. dysuria and penile discharge

553. a client with a benign prostatic hypertrophy (BPH) undergoes a transurethral resection of the
prostate and is receiving continuous bladder irrigation postoperatively. Which are the signs /
symptoms of a transurethral resection syndrome?
a. tachycardia and diarrhea
b. bradycardia and confusion
c. increased urinary output and anemia
d. decreased urinary output and bladder spasms

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554. A client with prostatitis resulting from kidney infection has received instructions on
management of the condition at home and prevention of recurrence. Which statement indicates that
the client understood the instructions?
a. stop antibiotic therapy when pain subsides
b. exercise as much as possible to stimulate circulation
c. exercise as much as possible to stimulate circulation
d. use a warm sitz bath and analgesics to increase comfort
e. keep fluid intake to a minimum to decrease the need to avoid

555. The nurse is monitoring an older client suspected of having a urinary tract infection for signs
of infection. Which signs / symptoms are likely to present first?
a. Fever
b. Urgency
c. Confusion
d. Frequency

556. The client who has a cold is seen in the emergency department with an inability to void.
Because the client has a history of benign prostatic hyperplasia, the nurse determines that the client
should be questioned about the use of which class of medications?
a. Diuretics
b. Antibiotics
c. Antitussives
d. Decongestant

557. A sulfonamide is prescribed for a client with a urinary tract infection. During review of the
client's record the nurse notes that the client is taking Warfarin sodium daily. Which prescription
should the nurse anticipate for this client?
a. discontinuation of Warfarin sodium
b. a decrease in the warfarin sodium dose
c. an increase in the warfarin sodium dosage
d. decrease in the usual dose of the sulfonamide

558. kidney transplantation, cyclosporine is prescribed for a client. Which laboratory result would
indicate an adverse effect from the use of this medication?
a. hemoglobin level of 14.0 g/dL (140g/L)
b. creatinine level of 0.6 mg/dL (53 mcmol/L)
c. blood urea nitrogen level of 25 mg/ dL (8.8 mmol/L)
d. fasting blood glucose level of 99 mg/ dL (5.5 mmol/L)

559. trimethoprim- sulfamethoxazole is prescribed for a client. The nurse should instruct the client
to report which symptom if it develops during the course of this medication therapy?
a. Nausea
b. Diarrhea
c. Headache
d. Sore Throat

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560. phenazopyridine hydrochloride is prescribed for a client for symptomatic relief of pain
resulting from a lower urinary tract infection. Which should the nurse reinforce to the client?
a. take the medication at bedtime
b. take the medication before meals
c. discontinue the medication if a headache occurs
d. reddish orange discoloration of the urine may occur

561. bethanechol chloride is prescribed for a client with urinary retention. Which disorder should
be a contraindication to the administration of this medication?
a. gastric atony
b. urinary strictures
c. neurogenic atony
d. gastroesophageal reflux

562. The nurse who is administering bethanechol chloride is monitoring for acute toxicity
associated with the medication. The nurse should check with the client for which sign of toxicity?
a. dry skin
b. dry mouth
c. bradycardia
d. signs of dehydration

563. Oxybutynin chloride is prescribed for a client with neurogenic bladder. Which sign would
indicate a possible Toxic effect related to this medication?
a. Pallor
b. Drowsiness
c. Bradycardia
d. Restlessness

564. A client with chronic kidney disease is receiving epoetin alfa.Which laboratory results would
indicate a therapeutic effect of the medication?
a. Hematocrit of 33% (0.33)
b. Platelet count of 400,000 mm3 (400 x 109/L)
c. White blood cell count of 6000 mm3 (6.0 x 109/L)
d. Blood urea nitrogen level of 15 mg/dL (5.25 mmol/L)

565. The nurse is reinforcing discharge instructions to a client receiving sulfadiazine. Which
should be included in the list of instructions?
a. restrict fluid intake
b. maintain a high fluid intake
c. decrease the dosage when symptoms are improving to prevent an allergic response
d. if that you're in turns dark brown call the primary health care provider immediately

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566. The nurse is preparing to reinforce a teaching plan for a client who is undergoing cataract
extraction with an intraocular implant. Which home-care measures should the nurse include in the
plan?
a. To avoid activities that require bending over
b. to contact the surgeon if eye scratchiness occurs
c. to take acetaminophen for minor eye discomfort
d. to place and eye shield on the surgical eye at bedtime
e. that episodes of sudden severe pain in the eye are expected
f. to contact the surgeon if a decrease in visual Acuity occurs

567. The nurse is assisting with developing a teaching plan for the client with glaucoma. Which
Instruction should the nurse suggest to include in the plan of care.
a. decrease the amount of salt in the diet
b. decrease of fluid intake to control the intraocular pressure
c. avoid reading the newspaper and watching television
d. on medications may need to be administered for the rest of your life

568. The nurse is assigned to care for a client with a detached retina. Which finding should the
nurse expect to be documented in the client's record?
a. blurred vision
b. pain in the affected eye
c. a yellow discoloration of the sclera
d. a sense of a curtain falling across the field of vision

569. The nurse is assigned to care for a client with a diagnosis of detached retina. Which findings
would indicate that bleeding has occurred as a result of retinal detachment? Select all that apply.
a. Total loss of vision
b. Vision may be cloudy
c. a reddened conjunctiva
d. a sudden sharp pain in the eye
e. complaints of a burst of black spots or floaters
f. vision is clear straight ahead but not to the right

570. a client arrives in the emergency department after an automobile crash. The client's head hit
the steering wheel and a hyphema has been diagnosed. Which position should the nurse prepare to
position the client?
a. flat on bed rest
b. on bed rest in a semi Fowler's position
c. in lateral position on the unaffected side
d. in the lateral position on the affected side

571. A client sustains a contusion of the eyeball after a traumatic injury with a blunt object. The
nurse should take which immediate action?
a. apply ice to the affected eye
b. irrigate the eye with cool water
c. notify the primary health care provider
d. accompany the client to the emergency department

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572. a client sustains a chemical eye injury from a splash of battery acid. The nurse should prepare
the client for which immediate measure?
a. checking visual acuity
b. covering the eye with a pressure patch
c. swabbing the eye with an antibiotic ointment
d. irrigating the eye with sterile normal saline

573. The nurse is caring for a client after enucleation and notes the presence of bright red drainage
on the dressing. The nurse should take which appropriate action?
a. document the finding
b. continue to monitor vital signs
c. report the findings to the registered nurse
d. mark the drainage on the dressing in monitor for any increase in bleeding

574. The nurse is preparing to administer ear drops to an adult client. The nurse administers the
ear drops by which technique?
a. pulling the pinna up and back
b. pulling the earlobe down and back
c. tilting the client's head forward and down
d. instructing the client to stand and lean to one side

575. The nurse is caring for a client who is hearing-impaired and should take which approach to
facilitate communication?
a. speak loudly
b. speak frequently
c. speak in a normal tone
d. speak directly into the impaired ear

576. a client arrives at the emergency department with a foreign body in the left ear that has been
determined to be an insect. Which initial intervention should the nurse anticipate to be prescribed?
a. Irrigation of the ear
b. Instillation of antibiotic ear drops
c. Instillation of corticosteroid ointment
d. Instillation of mineral oil or diluted alcohol

577. The nurse notes that the primary health care provider has documented a diagnosis of
presbycusis on the client's chart. Which explanation should the nurse give to the client to explain this
condition?
a. Tinnitus that occurs with aging
b. Nystagmus that occurs with aging
c. A conductive hearing loss that occurs with aging
d. Sensorineural hearing loss that occurs with aging

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578. A client with Meniere's disease is experiencing severe vertigo. The nurse reinforces
instructions to the client to do which to assist with controlling vertigo?
a. increase sodium in the diet
b. lie still and watch television
c. avoid sudden head movements
d. increase fluid intake to 3000 mL/day

579. The nurse is assigned to care for a client hospitalized with Meniere's disease. The nurse
expects which would most likely be prescribed for the client?
a. low fat diet
b. low sodium diet
c. low cholesterol diet
d. low carbohydrate diet

580. A client is diagnosed with glaucoma. Which data gathered by the nurse indicate a risk factor
associated with glaucoma?
a. cardiovascular disease
b. a history of migraine headaches
c. frequent urinary tract infections
d. frequent upper respiratory infections

581. Betaxolol hydrochloride eye drops I've been prescribed for the client with glaucoma. Which
nursing action is most appropriate related to monitoring for the side / adverse effects of this
medication?
a. monitoring temperature
b. monitoring blood pressure
c. monitoring peripheral pulses
d. checking the blood glucose level

582. The nurse assists with preparing the client for irrigation us prescribed by the primary
healthcare provider. Which action should the nurse plan to take?
a. warm irrigation solution to 98F ( 36.6C )
b. position the client with the affected side up after the irrigation
c. direct a slow, steady stream of irrigation solution towards the eardrum
d. assist the client with turning his or her head so that the ear to be irrigated is facing upward

583. In preparation for cataract surgery, the nurse is to administer cyclopentolate eye drops. The
nurse administers eye drops to knowing that which is the purpose of this medication?
a. to produce miosis of the operative eye
b. to dilate the pupil of the operated eye
c. to provide lubrication to the operative eye
d. to constrict the pupil of the operative eye

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584. The nurse is providing instructions to a client who is self-administering eye drops. To
minimize the systemic effects that eye drops can produce, the client is instructed to perform which
action?
a. Eat before instilling the drops
b. Swallow several times after instilling the drops
c. Blink vigorously to encourage tearing after instilling the drops
d. Include the nasolacrimal ducts with a finger over the inner canthus for 30 to 60 seconds after
installing the drops

585. The client is receiving an eye drop and eye ointment to the right eye. Which action should the
nurse take?
a. Administer the eye drops first, followed by the eye ointment
b. Administer the eye ointment first, followed by the eye drop
c. Administer the eye drop, wait 10 minutes and administer the eye ointment
d. Administer the eye ointment, wait 10 minutes, and administer the eye drop

586. The nurse is caring for a client with glaucoma. Which medication prescribed for the client
should the nurse question?
a. Betaxolol
b. Pilocarpine
c. Atropine sulphate
d. Pilocarpine hydrochloride

587. The nurse is preparing to administer eye drops. Which interventions should the nurse take to
administer the drops? Select all that apply
a. wash hands
b. put on gloves
c. place drop in the conjunctival sac
d. pull the lower lid down against the cheek bone
e. instruct the client to squeeze the eyes shut after instilling the eye drop
f. instruct the client to tilt the head forward, Open the eyes, and look down

588. The client was just admitted to the hospital to rule out a gastrointestinal bleed. The client has
brought several bottles of medications prescribed by different Specialists. During the admission
assessment of the client states, “ lately, I have been hearing some roaring sounds in my ears,
especially when I am alone.” Which medication should the nurse determine to be the cause of the
client's complaint?
a. Doxycycline
b. Atropine sulfate
c. Acetylsalicylic acid
d. Diltiazem hydrochloride

589. Pilocarpine hydrochloride is prescribed for the client with glaucoma. Which medication
should the nurse plan to have in the event of systemic toxicity?
a. Metipranolol
b. Atropine sulphate
c. Timolol maleate

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 d. Carteolol hydrochloride
590. A miotic medication has been prescribed for the client with glaucoma. The client asks the
nurse about the purpose of the medication. The nurse should tell the client which purpose?
a. The medication will help dilate the eye to prevent an increase in eye pressure
b. The medication relax the muscles of the eyes and prevent to blurred vision
c. The medication causes the pupil to constrict and will lower the pressure in the eye
d. The medication will help block the responses that are sent to the muscles in the eye

591. A client with a seizure disorder is being admitted to the hospital. Which should the nurse plan
to implement for this client? Select all that apply
a. Pad the bed’s side rails
b. Place an airway at the bedside
c. Place oxygen equipment at the bedside
d. Place suction equipment at the bedside
e. Tape a padded tongue blade to the wall at the head of the bed

592. The client has undergone a computed tomography scanning with a contrast medium. Which
statement by the client demonstrates an understanding of the post procedure care?
a. I should drink extra fluids for the remainder of the day
b. I should not take any medication for at least 4 hours
c. I should eat lightly for the remainder of the day
d. I should rest quietly for the remainder of the day

593. The nurse is caring for a client with increased intracranial pressure. Which change in vital
signs would occur if ICP is rising?
a. Increasing temperature, increasing pulse, increasing respirations, decreasing BP
b. Decreasing temperature, decreasing pulse, increasing respirations, decreasing BP
c. Decreasing temperature, increasing pulse, decreasing respirations, increasing BP
d. Increasing temperature, decreasing pulse, decreasing respirations , increasing BP

594. The nurse observes the unlicensed assistive personnel positioning the client with increased
intracranial pressure. Which positioning would require intervention by the nurse?
a. Head midline
b. Head turned to the side
c. Neck in neutral position
d. Head of bed elevated 30 to 45 degrees

595. The client recovering from a head injury is arousable and participating in care. The nurse
determines that the client understands measures to prevent elevation in intracranial pressure if the
nurse observes the client doing which activity?
a. Blowing the nose
b. Isometric exercises
c. Coughing vigorously
d. Exhaling during repositioning

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596. The client has clear fluid leaking from the nose after a basilar skull fracture. The nurse
determines that this is cerebrospinal fluid if the fluid meets which criteria?
a. Is grossly bloody in appearance and has a pH of 6
b. Clumps together on the dressing and has a pH of 7
c. Is clear in appearance and tests negative for glucose
d. Separates into concentric rings and tests positive for glucose

597. The client is admitted to the hospital for observation with a probable minor head injury after
an automobile crash. The nurse expects the cervical collar will remain in place until which time?
a. The client is taken for spinal x-rays
b. The family comes to visit after surgery
c. The nurse needs to provide physical care
d. The primary health care provider reviews the x-ray results

598. The client was seen and treated in the emergency department for a concussion. Before
discharge, the nurse explains the signs/ symptoms of a worsening condition. The nurse determines
that the family needs further teaching if they state they will return to the ED if the client experiences
which sign/symptom?
a. Vomiting
b. Minor headache
c. Difficulty speaking
d. Difficulty awakening

599. The nurse is caring for a client who has undergone craniotomy with a supratentorial incision.
The nurse should plan to place the client in which position postoperatively?
a. Head of bed flat, head and neck midline
b. Head of the bed flat, head turned to the non-operative side
c. Head of bed elevated 30 to 45 degrees, head and neck midline
d. Head of the bed elevated 30 to 45 degrees, head turned to the operative side

600. The client with a cervical spine injury has Crutchfield tongs applied in the emergency
department. The nurse should perform which essential action when caring for this client?
a. Providing a standard bed frame
b. Removing the weights to reposition the client
c. Removing the weights if the client is uncomfortable
d. Comparing the amount of prescribed weights with the amount in use

Finished Test #3!

Keep Studying!

Love you all <3

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 Saunders Exam Practice Questions Test #4
601. The nurse has provided discharge instructions to a client with an application of a Halo device.
The nurse determines that the client needs further teaching if which statement is made?
a. I will use a straw for drinking
b. I will drive only during the daytime
c. I will use caution because the device Alters balance
d. I will wash the skin daily under the lambswool liner of the best

602. The nurse is caring for the client who has suffered a spinal cord injury. The nurse further
monitors the client for signs of autonomic dysreflexia and suspects this a complication if which
signs/symptoms are noted?
a. Sudden tachycardia
b. Pallor of the face and neck
c. Severe, throbbing headache
d. Severe and sudden hypotension

603. The client with spinal cord injury is prone to experiencing autonomic dysreflexia. The least
appropriate measure to minimize the risk of autonomic dysreflexia is which action?
a. strictly adhering to a bowel retraining program
b. keeping the linen wrinkle free under the client
c. avoiding unnecessary pressure on the lower limbs
d. limiting bladder catheterization to once every 12 hours

604. a client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia.
After checking Vital Signs which immediate action should the nurse take?
a. Raise the head of the bed and remove the noxious stimulus
b. Lower the head of the bed and remove the noxious stimulus
c. Lower the head of the bed in administering antihypertensive agent
d. Remove the noxious stimulus and administer an antihypertensive agent

605. The client is having a lumbar puncture performed. The nurse should place the client in which
position for the procedure?
a. Supine in semi Fowler's
b. Prone in a slight Trendelenburg’s
c. Prone with a pillow under the abdomen
d. Side lying with legs pulled up in chin to the chest

606. The client with myasthenia gravis is suspected of having a cholinergic crisis. Which signs /
symptoms indicate this crisis is taking place?
a. Ataxia
b. Mouth sores
c. Hypothermia
d. Hypertension

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607. The client is receiving meperidine hydrochloride for pain. Which signs / symptoms are side
and adverse effects of this medication? Select all that apply.
a. Diarrhea
b. Tremors
c. Drowsiness
d. Hypotension
e. Urinary frequency
f. Increased respiratory rate

608. The client with myasthenia gravis becomes increasingly weak. The primary health care
provider prepares to identify whether the client is reacting to an overdose of the medication
(cholinergic crisis) or increasing severity of the disease (myasthenic crisis). An injection of
edrophonium is administered. Which change in condition indicates the client is in a cholinergic
crisis?
a. No change in condition
b. Complaints of muscle spasms
c. An improvement of the weakness
d. A temporary worsening of the condition

609. Carbidopa-levodopa is prescribed for a client with Parkinson's disease, the nurse monitors the
client for adverse effects of the medication. Which sign / symptom indicates the client is
experiencing an adverse effect?
a. Pruritus
b. Tachycardia
c. Hypertension
d. Impaired voluntary movements

610. Phenytoin, 100 mg orally three times daily, has been prescribed for a client for seizure
control. The nurse reinforces instructions regarding the medication to the client. Which statement by
the client indicates an understanding of the instructions?
a. “I will use a soft toothbrush to brush my teeth”
b. “It is all right for me to break the capsules to make it easier for me to swallow them”
c. “If I forget to take my medication I can wait until the next dose and eliminate that dose”
d. “If my throat becomes sore it's a normal effect of the medication and it's nothing to be
concerned about”

611. The client is taking phenytoin for seizure control, and a blood sample for a serum drug level
is drawn. Which laboratory finding indicates a therapeutic serum drug result?
a. 5 mcg/mL (19.84 mcmol/L)
b. 15 mcg/mL (59.52 mcmol/L)
c. 25 mcg/mL (99.2 mcmol/L)
d. 30 mcg/mL (119.0 mcmol/L)

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612. Ibuprofen is prescribed for a client. Which instruction should the nurse give the client about
taking this medication?
a. take with 8 oz of milk
b. taking the morning-after arising
c. take 60 minutes before breakfast
d. take at bedtime on an empty stomach

613. The nurse is caring for a client who is taking phenytoin for control of seizures. During data
collection, the nurse notes that the client is taking birth control pills. Which information should the
nurse provide to the client?
a. pregnancy should be avoided while taking phenytoin
b. the client may stop taking the Phoenix on if it is causing severe gastrointestinal effects
c. the potential for decrease effectiveness of birth control pills exist while taking phenytoin
d. the increase risk of thrombophlebitis exist while taking phenytoin and birth control pills
together

614. The client with trigonal neuralgia is being treated with carbamazepine. Which laboratory
results indicate the client is securing an adverse effect of this medication?
a. sodium level, 140 mEq/L 9140 mmol/L)
b. uric acid level 5.0 mcg/dL (0.3mmol/L)
c. white blood cell count 3000 mm3(3 x 109/L)
d. blood urea nitrogen level 15 mg/dL (5.4 mmol/L)

615. The client with myasthenia gravis is receiving pyridostigmine. The nurse monitors for signs
and symptoms of cholinergic Crisis caused by overdose of the medication. The nurse checks the
medication Supply to ensure that which medication is available for administration and if a
cholinergic crisis occurs?
a. Vitamin K
b. Acetylcysteine
c. Atropine sulphate
d. Protamine sulphate

616. The nurse is one of several people who witnessed a vehicle hit a pedestrian at a fairly low
speed on a small Street. The individual is days and tries to get up, the leg appears fractured. The
nurse should plan to perform which action?
a. try to manually reduce the fracture
b. assist the person with getting up and walking to the sidewalk
c. leave the person for a few moments to call an ambulance
d. stay with the person and encourage the person to remain still

617. The nurse Witnesses a client sustained a fall into specs that the client's leg may be fractured.
Which action is the priority?
a. take a set of vital signs
b. call the radiology department
c. immobilize the leg for moving the client
d. reassure the client that everything will be fine

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618. a client with a hip fracture a Senora's y Buck's extension traction is being applied before
surgery. The nurses response is based on the understanding that Buck's extension traction has which
primary function?
a. allows bony healing to begin before surgery
b. provides rigidity mobilization of the fracture site
c. lengthens the fractured leg to prevent severing of the blood vessels
d. provides Comfort by reducing muscle spasms and provides fracture immobilization

619. The nurse is evaluating the pin sights of a client in skeletal traction. The nurse would be least
concerned with which finding?
a. Inflammation
b. Serous drainage
c. Pain at pin sight
d. Purulent drainage

620. The nurse is caring for the client who has had skeletal traction applied to the left leg. The
client is complaining about severe left leg pain. Which action should the nurse take first?
a. provide pin care
b. check the client's alignment in bed
c. medicate the client with an analgesic
d. call the primary health care provider

621. The nurse has provided instructions regarding specific leg exercises for the client
immobilized in right skeletal lower leg traction. The nurse determines that the client needs further
teaching if the nurse observes the client doing which activity?
a. Pulling up on the trapeze
b. Flexing and extending the feet
c. Doing quadriceps- setting and gluteal setting exercises
d. Performing active range of motion to the right ankle and knee

622. The nurse is checking the casted extremity of a client. The nurse should check for which sign
indicates an infection?
a. dependant edema
b. diminished distal pulse
c. presence of a hot spot on the cast
d. coolness and pallor of the extreme

623. A client has sustained a closed fracture and has just had a cast applied to the affected arm.
The client is complaining of intense pain. The nurse elevated the limb, applied a nice bag, and
administered an analgesic, which was ineffective and relieving pain. The nurse interprets that this
pain may be caused by which condition?
a. infection under the cast
b. anxiety of the client
c. impaired tissue perfusion
d. the newness of the fracture

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624. The nurse is assigned to care for a client with multiple traumas who is admitted to the
hospital. The client has a leg fracture, and a plaster cast has been applied. In positioning the cast of
leg the nurse should perform which intervention?
a. Keep the leg in a level position
b. Elevate the leg for 3 hours, and put it flat for 1 hour
c. Keep the leg level for 3 hours and elevated for 1 hour
d. Elevate the leg on pillows continuously for 24 to 48 hours

625. A client is complaining of skin irritation from the edges of a cast applied the previous day.
The nurse should plan for which intervention?
a. Massaging the skin at the rim of the cast
b. Petaling the cast edges with adhesive tape
c. Using a rough I'll just move the cast edges
d. Applying lotion to the skin at the rim of the cast

626. The nurse is preparing a list of cast care instructions for a client who has just had a plaster
cast applied to his right forearm. Which instruction should the nurse include on the list? Select all
that apply.
a. Keep the cast and extremity elevated
b. The cast needs to be kept clean and dry
c. Allow the webcast 24 to 72 hours to dry
d. Expect tingling and numbness in the extremity
e. Use a hair dryer set on warm to hot setting to dry the cast
f. Use a soft padded object that will fit under the cast to scratch the skin under the cast

627. The nurse is planning to reinforce instructions to the client about how to stand on crutches. In
the instructions the nurse should plan to tell the client to place the crutches in which position?
a. 3 in to the front and side of the client's toes
b. 8 in to the front inside of the client's toes
c. 15 in to the front inside of the client's toes
d. 20 in to the front and side of the client's toes

628. The nurse is evaluating the client's use of a cane for left-sided weakness. The nurse should
intervene and correct the client if the nurse observed that the client performed which action?
a. Holds the cane on the right side
b. Move the cane when the right leg is moved
c. Leans on the cane when the right leg swings through
d. Keeps the cane 6in out to the side of the right foot

629. The nurse is caring for a client with a fresh application of a plaster leg cast. The nurse should
plan to prevent the development of compartment syndrome by which action?
a. elevating the limb and applying ice to the affected leg
b. elevating a limb and covering it with bath blankets
c. keeping the lake horizontal and applying ice to the affected leg
d. placing the leg in a slightly dependant position and applying ice

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630. A client is being discharged after application of a plaster leg cast. The nurse determines that
the client understands proper care of the cast if the client makes which statement?
a. I need to avoid getting the cast wet
b. I will use my fingertips to lift and move the leg
c. I need to cover the passive leg with warm blankets
d. I can use a padded coat hanger and key scratch under the cast

631. The client has been taking medication for rheumatoid arthritis for 3 weeks. During the
administration of etanercept, it is most important for the nurse to collect which data?
a. the white blood cell and platelet counts
b. a metallic taste in the mouth with a loss of appetite
c. whether the client is experiencing fatigue and Joint pain
d. whether the client is experiencing itching and edema at the injection site

632. Alendronate is prescribed for a client with osteoporosis in the nurse and provides instructions
for the administration of the medication. Which instruction should the nurse reinforce?
a. take the medication at bedtime
b. take the medication in the morning with breakfast
c. lie down for 30 minutes after taking the medication
d. take the medication with a full glass of water after rising in the morning

633. The nurse is monitoring a client receiving baclofen for side effects related to the medication.
Which should indicate the client is experiencing a side effect?
a. Polyuria
b. Diarrhea
c. Drowsiness
d. Muscular excitability

634. During the monitoring of a client's response to disease-modifying antirheumatic drugs

(DMARDs), which finding should the nurse interpret as acceptable responses? Select all that apply.
a. Symptom control during periods of emotional distress
b. Normal white blood cell, platelet and neutrophil counts
c. Radiological findings that shown on progression of joint degeneration
d. An increased range of motion in the affected joints 3 months into therapy
e. Inflammation irritation at the injection site three days after injection is given
f. A low-grade temperature when rising in the morning that remains throughout the day

635. A client with acute muscle spasms has been taking baclofen. The client calls the clinic nurse
because of the continuous feelings of weakness and fatigue and asks the nurse about discontinuing
the medication. The nurse should make which appropriate response to the client?
a. “you should never stop the medication”
b. “it is best that you taper with the Dos if you intend to stop the medication”
c. “it is okay to stop the medication if you think that you can tolerate the muscle spasms”
d. “weakness and fatigue commonly occur and will diminish with continued medication use”

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636. The nurse is reviewing the laboratory studies on a client receiving dantrolene sodium. Which
laboratory results would identify an adverse effect associated with the administration of this
medication?
a. Creatinine
b. Liver function tests
c. Blood urea nitrogen
d. Hematological function tests

637. The nurse is reviewing the record of a client who has been prescribed baclofen. Which
disorder should alert the nurse to contact the primary health care provider?
a. A seizure disorder
b. Hyperthyroidism
c. Diabetes mellitus
d. Coronary artery disease

638. Cyclobenzaprine is prescribed for a client to treat muscle spasms, and the nurse is reviewing
the client's record. Which disorder would indicate a need to contact the primary health care provider
regarding the administration of this medication?
a. Glaucoma
b. Emphysema
c. Hyperthyroidism
d. Diabetes mellitus

639. Dantrolene sodium is prescribed for a client experiencing flexor spasms, and the client asks
the nurse about the action of the medication. The nurse responds knowing which is the therapeutic
action of this medication?
a. depressive spinal reflexes
b. acts directly on the skeletal muscle to relieve spasticity
c. acts within the spinal cord to suppress hyperactive reflexes
d. acts on the central nervous system to suppress spasms

640. The nurse is reinforcing discharge instructions to a client receiving baclofen. Which should
the nurse include in the instructions?
a. restrict fluid intake
b. avoid the use of alcohol
c. stop the medication of diarrhea occurs
d. notify the primary health care provider is fatigue occurs

641. Which individual is least at risk for the development of Kaposi's sarcoma?
a. a kidney transplant client
b. a male with a history of same-sex partners
c. a client receiving antineoplastic medications
d. an individual working environment where exposure to asbestos exists

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642. The nurse prepares to give a bed bath and change the bed linens for a client with cutaneous
Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which
should the nurse incorporated in the plan during the bathing of this client
a. wearing gloves
b. wearing a gown and gloves
c. wearing a gown, gloves, and a mask
d. wearing a gown and gloves to change the bed linens and gloves only for the bath.

643. The client is suspected of having systemic lupus erythematosus (SLE). The nurse monitors
the client, knowing that which is one of the initial characteristic signs of SLE?
a. weight gain
b. subnormal temperature
c. elevated red blood cell count
d. rash across the face across the nose and on the cheeks

644. The client diagnosed with pemphigus is being seen in the clinic regularly. The nurse should
plan care based on which description of this condition?
a. the presence of tiny red vesicles
b. an autoimmune disease that causes blistering in the epidermis
c. the presence of skin vesicles found along the nerve caused by a virus
d. the presence of red raised papules and large plots covered by silvery scales

645. Which intervention should be implemented in the care of a client at high risk for an allergic
response to a latex allergy? select all that apply.
a. Use non latex gloves
b. Use medications from glass ampules
c. Place the client in a private room only
d. Do not puncture the rubber stoppers with needles
e. Keep a latex safe Supply cart available in the client area
f. Use a blood pressure cuff from an electronic device only to measure the blood pressure

646. The nurse is assisting with planning the care of a client with a diagnosis of
immunodeficiency. The nurse should incorporate which intervention as a priority in the plan of care?
a. protecting the client from infection
b. providing emotional support to decrease fear
c. encouraging discussion about Lifestyle Changes
d. identifying factors that decrease the immune function

647. The client calls the office of the primary health care provider and states to the nurse that they
were just stung by a bumble bee well gardening. The client is afraid of a severe reaction because
they're never experienced such a reaction just one week ago. What should be the appropriate nursing
action?
a. advise the client to soak the site in hydrogen peroxide
b. ask the client if they've ever sustained a bee sting in the past
c. tell the client to call an ambulance for transport to the emergency room
d. tell the client not to worry about the sting unless difficulty with breathing occurs

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648. The nurse is assisting with the administration of immunizations at a Health Care Clinic. The
nurse should understand that immunization provides which protection?
a. protection from all diseases
b. innate immunity from disease
c. natural immunity from disease
d. acquired immunity from disease

649. The nurse is assigned to care for a client diagnosed with systemic lupus erythematosus (SLE).
The nurse should plan care considering which factor regarding this diagnosis?
a. Local rash occurs as a result of allergy
b. It is a disease caused by overexposure to sunlight
c. A continuous release of histamine in the body causes the disease
d. It is an inflammatory disease of collagen contained in connective tissue

650. The camp nurse prepares to instruct a group of children about Lyme disease. Which
information should the nurse include in the instructions?
a. Lyme disease is caused by a tick carried by deer
b. Lyme disease is caused by contamination from cat feces
c. Lyme disease can be contagious by skin contact with an infected individual
d. Lyme disease can be caused by the inhalation of spores from bird droppings

651. The client is diagnosed with Stage 1 of Lyme disease. The nurse should check the client for
which characteristic of this stage?
a. Arthralgia
b. Flu like symptoms
c. Enlarged and inflamed joints
d. Signs of a neurological disorder

652. The client arrives at the health care clinic and states the nurse that they were just bitten by a
tick and would like to be tested for Lyme disease. The client tells the nurse that they remove the tick
and flush it down the toilet which nursing action is appropriate?
a. Refer the client for a blood test immediately
b. Inform the client that there is not a test available for Lyme disease
c. Tell the client that testing is not necessary unless arthralgia develops
d. Instruct the client to return in four to six weeks to be tested, because testing before this time
is not reliable

653. The nurse, a cub scout leader, is preparing a group of cubs to go for an overnight camping
trip and instructs them about the methods to prevent Lyme disease. Which statement by one of the
Cub Scouts indicates a need for further teaching?
a. I need to bring a hat to wear during the trip
b. I should wear a long sleeve tops and long pants
c. I Should not use insect repellent because it will attract the ticks
d. I need to wear clothes shoes and socks that can be pulled up over my pants

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654. The client with acquired immunodeficiency syndrome (AIDS) is diagnosed with cutaneous
Kaposi's sarcoma based on this diagnosis the nurse should determine that this has been confirmed by
which finding?
a. swelling in the genital area
b. swelling in the lower extremities
c. punch biopsy of the cutaneous lesions
d. appearance of reddish blue lesions on the skin

655. The client brought to the emergency department is experiencing an anaphylactic reaction
from eating shellfish. The nurse should Implement which immediate action?
a. administering epinephrine
b. maintaining a patent Airway
c. administering a corticosteroid
d. instructing the client on the importance of obtaining a Medic Alert bracelet

656. A client diagnosed with AIDS is taking nevirapine. The nurse should monitor for which side /
adverse effects of the medications?
a. Rash
b. Hepatotoxicity
c. Hyperglycemia
d. Peripheral neuropathy
e. Reduced bone mineral density

657. The client diagnosed with AIDS has begun therapy with zidovudine. The nurse should
monitor which laboratory result during treatment with this medication
a. Blood culture
b. Blood glucose level
c. Blood urea nitrogen
d. Complete blood count

658. The nurse is reviewing the results of a serum laboratory study drawn on a client diagnosed
with AIDS who is receiving Didanosine. The nurse determines that the client may have the
medication discontinued by the primary health care provider if which significantly elevated result is
noted?
a. serum protein
b. blood glucose
c. serum amylase
d. serum creatinine

659. The nurse is caring for a post renal transplantation client with a prescription for cyclosporine.
If the nurse notes an increase in one of the client's vital signs in the client is complaining of a
headache, which Vital sign is most likely to be increased?
a. Pulse
b. Respirations
c. Blood pressure
d. Pulse oximetry

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660. Amikacin is prescribed for a client with a diagnosed bacterial infection. The nurse instructs
the client to contact the primary healthcare provider immediately if which occurs?
a. Nausea
b. Lethargy
c. Hearing loss
d. Muscle aches

661. The nurse is assigned to care for a client diagnosed with cytomegalovirus retinitis and AIDS
who is receiving foscarnet. the nurse should monitor the results of which laboratory study while the
client is taking this medication?
a. CD4+ cell count
b. Lymphocyte count
c. Serum albumin level
d. Serum creatinine level

662. The client with diagnosed AIDS and pneumocystis jiroveci infectionHas been receiving
pentamidine. The client develops a temperature of 101 degrees Fahrenheit (38.3C). The nurse
continues to monitor the client, knowing that this sign would most likely indicate which condition?
a. the dose of the medication is too low
b. the client is experiencing toxic effects of the medication
c. the client has developed an adequacy of thermoregulation
d. a result of another infection caused by the Leukopenic effects of the medication

663. saquinavir is prescribed for a client who is diagnosed with HIV seropositive. The nurse
reinforce medication instructions about which Health Care measures the client?
a. avoid sun exposure
b. eat low-calorie foods
c. eat foods that are low in fat
d. take the medication on empty stomach

664. Ketoconazole prescribed for a client with a diagnosis of candidiasis. Which intervention
should the nurse include when administering this medication? Select all that apply.
a. Restrict fluid intake
b. Monitor liver function studies
c. Instruct the client to avoid alcohol
d. Administer the medication with an antacid
e. Instruct the client to avoid exposure to the Sun
f. Administer the medication on an empty stomach

665. The client who is diagnosed with HIV seropositive has been taking stavudine. the nurse
should monitor which parameter closely while the client is taking this medication?
a. Gait
b. Appetite
c. Level of consciousness
d. Hemoglobin and hematocrit blood levels

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666. The nurse is assigned to care for a client experiencing Disturbed thought processes. The nurse
is told that the client believes that their food is being poisoned. Which communication technique
should the nurse plan to use to encourage the client to eat?
a. open ended questions in silence
b. focussing on self disclosure regarding food preferences
c. stating the reasons that the client may not want to eat
d. offering opinions about the necessity of adequate nutrition

667. The nurse is assigned to care for a client admitted to the hospital after sustaining an injury
from a house fire. Decline attempted to save a neighbour involved in the fire, but despite the client's
efforts, the neighbour died. Which action should the nurse take to enable the client to work through
the meaning of the crisis?
a. identifying the client's ability to function
b. identifying the clients potential for self-harm
c. inquiring about the client's feelings that may affect coping
d. inquiring about the client's perception of the cause of the neighbours death

668. The nurse is assisting with data collection on a client admitted to the psychiatric unit. After
review Of the obtained data, the nurse should identify which as a priority concern?
a. the clients report of not eating or sleeping
b. the presence of bruises on the client's body
c. the clients report of self-destructive thoughts
d. the family member is disapproving of the treatment

669. Laboratory work is prescribed for a client who has been experiencing delusions. When the
laboratory technician approaches a client to obtain a specimen of the client's blood, the client begins
to shout, “ you're all vampires. Let me out of here!” The nurse present at the time should respond
with which question or statement?
a. “The technician is not going to hurt you but is going to help”
b. “Are you fearful and think that others may want to hurt you”
c. “What makes you think that the technician wants to hurt you”
d. “The technician will leave and come back later for your blood”

670. An intoxicated client is brought to the emergency department by local police. The client is
told that the primary health care provider will be in to see the client in about 30 minutes. The client
becomes very loud and inoffensive and wants to be seen by the primary health care provider
immediately. The nurse is assisting to care for the client to take which appropriate nursing
intervention?
a. Watch the behaviour escalate before intervening
b. Attempt to talk with the client to deescalate the behaviour
c. Offer to take the client to an examination room until he or she can retrieve
d. Inform the client that he or she will be asked to leave if the behaviour continues

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671. A client is admitted to a psychiatric unit for treatment of a psychotic disorder. The client is at
the lot exit door and is shouting, “Let me know! There's nothing wrong with me! I don't belong
here!” The nurse identifies this Behavior as which defense mechanism?
a. Denial
b. Projection
c. Regression
d. Rationalize

672. A client says to the nurse, “ I'm going to die, and I wish my family would stop hoping for a
cure! I get so angry when they carry on like this! After all, I'm the one who's dying.” Which
therapeutic response should the nurse make to the client?
a. “Have you shared your feelings with your family”
b. “I think we should talk more about your anger with your family”
c. “You’re you feeling angry that your family continues to help for you to be cured?”
d. “Well it sounds like you're being pretty pessimistic. After all, years ago people died of
pneumonia”

673. The nurse in a psychiatric unit is assigned to care for a client admitted to the unit 2 days ago.
During review of the client's records, the nurse notes that the Omission was a voluntary one. Based
on this type of emission, which would the nurse expect to note?
a. The client will be angry and will refuse care
b. The Client will participate in the treatment plan
c. The client will be very resistant to treatment measures
d. The client's family will be very resistant to treatment measures

674. The nurse enters a client's room, and the client immediately demands to be released from the
hospital. During review of the client's record, the nurse notes that the client was admitted two days
ago for the treatment of an anxiety disorder and that the Omission was a voluntary one. The nurse
reports the findings to the registered nurse and expects that the RN will take which action?
a. call the clients family
b. persuade the client to stay a few more days
c. contact the primary health care provider
d. tell the client that discharge is not possible at this time

675. A client is admitted to the psychiatric nursing unit. When collecting data from the client, the
nurse notes that the client was admitted on an involuntary status. Based on this type of emission,
which would the nurse expect to note?
a. the client presents a harm to self
b. the client requested the admission
c. the client consented to the admission
d. the client provided written application to the facility for admission

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676. Following a group therapy session, a client approaches the nurse and verbalizes I need for
seclusion because of uncontrollable feelings. The nurse reports the findings to the registered nurse
And expects that the RN will take which action?
a. Call the clients family
b. Place the client in seclusion immediately
c. Inform the client that seclusion has not been prescribed
d. Get a written prescription from the primary health care provider and obtain informed consent

677. The nurse is providing care for a client admitted to the hospital with a diagnosis of anxiety
disorder. The nurse is talking with the client and the client says, “ I have a secret that I want to tell
you. You won't tell anyone about it, will you?” Which is the appropriate nursing response?
a. “no I won't tell anyone”
b. “I cannot promise to keep a secret”
c. “if you tell me the secret, I will tell it to your doctor”
d. “if you tell me the secret, I will need to document it in your record”

678. The nurse in the mental health unit reviews the therapeutic and non-therapeutic
communication techniques with a nursing student. Which are therapeutic communication
techniques? Select all that apply.
a. Restating
b. Listening
c. Asking the client, “ why?”
d. Maintaining neutral responses
e. Giving advice, approval, or disapproval
f. Providing acknowledgement and feedback

679. The nurse is preparing a client for the termination phase of the nurse-client relationship.
Which task should the nurse appropriately plan for during this phase?
a. plan short-term goals
b. identify expected outcomes
c. assist with making appropriate referrals
d. assist with developing realistic solutions

680. The psychiatric nurse is greeted by a neighbour and a local grocery store. The neighbour says
to the nurse, “ how is Carole doing? She is my best friend and is seen at your clinic every week”
which is the appropriate nursing response?
a. “I cannot discuss any client situations with you”
b. “I am not supposed to discuss this, but because you are my neighbour, I can tell you that she
is doing great”
c. “You may want to know about Carol, so you need to ask her yourself so you can get the story
firsthand”
d. “I'm not supposed to discuss this, but because you are my neighbour, I can tell you that she
really has some problems”

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681. A client with delirium becomes agitated and confused at night. The best initial intervention
by the nurse is which action?
a. move the client next to the nurses station
b. using night light and turn off the television
c. keep the television and a soft light on during the night
d. play soft music during the night and maintain a well-lit room

682. The nurse is collecting data on a client who's actively hallucinating. Which nursing statement
would be therapeutic at this time?
a. I know you feel “they're out to get you” but this is not true
b. I can hear the voice, and she wants you to come to dinner
c. Sometimes people hear things are voices others can't hear
d. I talked to the voice of your hearing and they won't hurt you now

683. The nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs
of constipation and urinary retention, knowing that these problems are likely caused by which
situation?
a. poor dietary choices
b. lack of exercise and poor diet
c. inadequate dietary intake and dehydration
d. psychomotor retardation and side effects of medication

684. A client is admitted to the inpatient unit and is being considered for electroconvulsive therapy
(ECT). The client appears calm, but the family is hyper Vigilant and anxious. The client's mother
begins to cry and states, “ my child's brain will be destroyed. How can the doctor do this?” the nurse
should make which therapeutic response?
a. it sounds as though you need to speak to the psychiatrist
b. perhaps you'd like to see the ECT room and speak to the staff
c. your child has decided to have this treatment you should be supportive of the decision
d. it sounds as though you have some concerns about the ECT procedure. Why don't we sit
down together and discuss any concerns you may have?

685. Which nursing interventions are appropriate for a hospitalized client with Mania who is
exhibiting manipulative Behavior? Select all that apply.
a. Communicate expected behaviours of the client
b. Follow through about the consequences of behaviour in a non-punitive manner
c. Ensure that the client knows that he or she is not in charge of the nursing unit
d. Assist the client with developing a means of setting limits on personal Behavior
e. Enforce rules and inform the client that he or she will not be allowed to attend therapy groups
f. Be clear with the client regarding the consequences of exceeding limits set regarding
behaviour

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686. The nurse is preparing for the hospital discharge of a client with a history of command
hallucinations to harm self or others. The nurse instructs the client about interventions for
hallucinations and anxiety and determines that the client understands the Interventions when the
client makes which statement?
a. My medications won't make me anxious
b. I'll go to a support group and talk so that I won't hurt anyone
c. I won't get anxious or hear things if I get enough sleep and eat well
d. I can call my therapist when I pull loose sitting so I can talk about my feelings and plans and
not hurt anyone

687. The nurse observes that a client is psychotic, pacing, and agitated and is making aggressive
gestures. The client's speech pattern is rapid, and the client's affect is belligerent. Based on these
observations, which is the nurses immediate priority of care?
a. provide safety for the client and the other clients on the unit
b. provide the clients on the unit with a sense of comfort and safety
c. assist the staff with caring for the client in a controlled environment
d. offer The Client a Less stimulating area to calm down and Gain Control

688. The nurse is caring for a client diagnosed with catatonic stupor. The client is lying on the bed
body pulled into a fetal position. Which is the appropriate nursing intervention?
a. ask direct questions to encourage talking
b. leave the client alone and intermittently check on them
c. sit beside the client in silence and verbalize occasional open ended questions
d. take the client into the dayroom with other clients so they can help watch him

689. A mother of a Teenage client with an anxiety disorder is concerned about her daughter's
progress during discharge. She states that her daughter “ Stash's food, it's all the wrong things that
make her hyper active” and “ hangs out with the wrong crowd” well helping the mother prepare for
her daughter's just charge the nurse should make which suggestion?
a. the mother should restrict the daughters socializing time with friends
b. the mother should restrict the amount of chocolate and caffeine products in the home
c. the mother she keep the daughter out of school until she can adjust to the school environment
d. the mother consider taking time off work to help her daughter readjust to the home
environment

690. Mike line is unwilling to get out of the house for fear of “ doing something crazy in public”
because of the sphere the client remains homebound except when it is outside by the spouse. The
spouse asks the nurse, “ what is the name of my wife's disorder?” Which answer should the nurse
give to the spouse?
a. Agoraphobia
b. Hematophobia
c. Claustrophobia
d. Hypochondriasis

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691. A client has reported that crying spells have been a major problem over the past several
weeks and that the doctor said depression is probably the reason. The nurse observes that the client is
sitting slumped in the chair, and the clothes that the client is wearing do not fit well. The nurse
interprets that further data collection to focus on which assessment?
a. weight loss
b. sleep pattern
c. medication compliance
d. onset of the crying spells

692. A client was admitted to a medical unit with acute blindness. Many tests are performed, and
there seems to be no organic reason why this client cannot see. The nurse later learned that the client
became blind after witnessing a hit and run car crash in which a family of three was killed. The nurse
expects that the client may be experiencing which diagnosis?
a. Psychosis
b. Depression
c. Conversion disorder
d. Dissociative disorder

693. Amanda Klein announced to everyone in the dayroom that a stripper is coming to reform the
evening. When the psychiatric nurse's aide firmly States at the client's behaviour is not appropriate,
the man that client becomes verbally abusive and threatens physical violence to the nurse's aide.
Based on the analysis of the situation, the nurse determines that the appropriate action should be
which intervention?
a. Escort the man that client of his or her room
b. Orient the client to time, person and place
c. Tell the client that the behaviour is not appropriate
d. Tell the client that smoking privileges are revoked for 24 hours

694. The nurse knows documentation on a client's record that the client is experiencing delusions
of persecution. The nurse recognizes these types of delusions are characteristic of which thoughts?
a. The false belief that one is a very powerful person
b. The false belief that one is a very important person
c. The false belief that one's partner is being unfaithful
d. The false belief that one is being singled out for harmed by others

695. A client who is diagnosed with pedophilia and recently has been paroled as a sex offender
says, “ I'm in treatment and I have served my time. Now this group has posters all over the
neighbourhood with my photograph and details of my crime.” Which is an appropriate response by
the nurse?
a. when children are hurt the way you hurt them, people want you isolated
b. you're lucky it doesn't escalate into something pretty scary after your crime
c. you understand that people fear for their children, but you're feeling unfairly treated?
d. you seem angry, but you have committed serious crimes against several children, so your
neighbours are frightened

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696. The nurse is caring for a female client who was recently admitted to the hospital for anorexia
nervosa. The nurse enters the clients room and notes that the client is doing diggers push-ups. Which
nursing action is appropriate?
a. interrupt the client and wait here immediately
b. interrupt the client offered to take her for a walk
c. allow the client to complete your exercise program
d. tell the client that she's not allowed to exercise vigorously

697. Which are appropriate interventions for caring for the client undergoing alcohol withdrawal?
select all that apply
a. Monitor vital signs
b. Maintain an NPO status
c. Provide a safe environment
d. Address hallucinations therapeutically
e. Provide stimulation in the environment
f. Provide reality orientation as appropriate

698. The nursing student is creating a plan of care for the hospitalized client with bulimia nervosa.
The nursing instructor intervenes if the student documents which intervention in the plan that is not
specific to the disorder?
a. monitor intake and output
b. monitor electrolyte levels
c. observe for excessive exercise
d. monitor for the use of laxatives and diuretics

699. The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium.
The nurse should monitor for which symptoms?
a. hypotension, Ataxia, vomiting
b. stupor, agitation, muscular rigidity
c. hypertension, bradycardia, agitation
d. hypertension, disorientation, hallucinations

700. The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse, “ I
should get out of this bad situation” the most helpful response by the nurse should be which
statement?
a. “why don't you tell your husband about this?”
b. “this is not the best time to make that decision”
c. “What do you find Difficult about the situation?”
d. “I agree with you. You should get out of the situation”

701. The nurse is caring for a client who is suspected of being dependent on drugs. Which
question should be appropriate for the nurse to ask when collecting data from the client regarding
drug abuse?
a. Why did you get started on these drugs?
b. How much do you use in what effect does it have on you?
c. How long do you think you could take these drugs without someone finding out?

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 d. The nurse does not ask any questions because of the fear that the client is in denial and we'll
throw the nurse out of the room?
702. A client who's been drinking alcohol on a regular basis admits to having “ a problem” and it's
asking for assistance with the problem. The nurse should encourage the client to attend which
community group?
a. Al-Anon
b. Fresh Start
c. Families anonymous
d. Alcoholics Anonymous

703. A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two bed
hospital room. A newly admitted client will be assigned to this client's room. Which client should be
an appropriate Choice as his clients roommate?
a. a client with pneumonia
b. a client receiving diagnostic tests
c. a client who thrives on managing others
d. a client who could benefit from the client assistance at meal times

704. The nurse is assigned to care for a client at risk for alcohol withdrawal. The client's spouse
asks the nurse, “ when will the first signs of withdrawal appear?” The nurse should give which reply?
a. in 7 days
b. in 14 days
c. in 21 days
d. within a few hours

705. The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-
Anon group when the nurse hears the wife make which statement?
a. I no longer feel that I deserve to beatings my husband inflicts on me
b. My attendance at the meetings has helped me see that I provoked my husband's violence
c. I enjoy attending the meetings because they get me out of the house and away from my
husband
d. I can tolerate my husband's destructive behaviours now that I know they are common for
alcoholics

706. A female client with anorexia nervosa is a member of a support group. The client has
verbalized that she would like to buy some new clothes but her finances are limited. Group members
have brought some use closed for the client to replace your old clothes. The client said that new
clothes were much too tight, so she is reducing your calorie intake to 800 calories daily. The nurse
identifies this Behavior as which finding?
a. Normal
b. Regressive
c. Indicator of the client's ambivalence
d. Evidence of the clients altered in distorted body image

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707. A hospitalized client with a history of alcohol abuse tells the nurse, “ I'm leaving now. I have
to go. I don't want any more treatment. I have things that I have to do right away.” The client has not
been discharged. In fact the client is scheduled for an important diagnostic test to be performed in 1
hour. After the nurse discusses the concerns with the client, the client dresses in and begins to walk
out of the hospital room. Which is the appropriate nursing action?
a. call the nursing supervisor
b. call the security to block all exit areas
c. tell the client that she cannot return to this hospital again if she leaves now
d. restrain the client until the primary healthcare provider can be reached

708. The nursing student is asked to identify the characteristics of bulimia nervosa. Which
characteristic if identified by the student indicates a need to further research the disorder?
a. dental erosion
b. electrolyte imbalances
c. enlarged parotid glands
d. bodyweight well below ideal range

709. The nurse is caring for a client who has a history of opiate abuse and is monitoring a client
for signs of withdrawal. Which manifestations are specifically associated with withdrawal from
opioids?
a. dilated pupils, tachycardia, diaphoresis
b. yawning, irritability, diaphoresis, cramps and diarrhea
c. tachycardia, hypertension, sweating, and marked tremors
d. depressed feelings, High drug craving, fatigue, agitation

710. The nurse is monitoring the behaviour of a client and understands that the client with
anorexia nervosa manages anxiety by which action?
a. engaging in immoral Acts
b. always reinforcing self-approval
c. observing rigid rules and regulations
d. having the need to always make the right decision

711. The nurse is caring for an older adult client who has recently lost her husband. The client
says, “ no one cares about me anymore. All the people I loved her dead” which response by the nurse
is therapeutic?
a. right why not just pack it in
b. that seems rather unlikely to me
c. I don't believe that, and neither do you
d. you must be feeling all alone at this point

712. The nurse is planning care for a client who is being hospitalized because the client has been
displaying violent behaviour and is at risk for potential harm to others. The nurse should avoid which
intervention in the plan of care?
a. Facing the client when providing care
b. Ensuring that the security officer is within the immediate area
c. Keeping the door to the clients open when with the client

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 d. Assigning the client to a room at the end of the hall to prevent disturbing other clients

713. Which behaviours observed by the nurse might lead to the suspicion that a depressed
adolescent child could be suicidal?
a. the client gives away a DVD and a cherished autograph picture of the performer
b. the client runs out of the Therapy Group swearing at the group leader and then runs to the
room
c. the client gets angry with her roommate when the roommate far as their clothes without
asking
d. the client becomes angry while speaking on the cell phone and slammed the phone down on
her bed

714. A client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. What is
the nurses most important intervention to maintain client safety?
a. request that appear remain with the client at all times
b. remove the clients clothing and place the client in hospital gown
c. assign a staff member who will remain with him or her at all times
d. Bring the client to seclusion room where all potentially dangerous articles are removed

715. The police arrived at the emergency department with a client who has seriously lacerated
both wrists. Which is the initial nursing action?
a. administer an anti-anxiety agents
b. examine and treat the wound site
c. secure and record a detailed history
d. encourage and assist the client with venting their feelings

716. The nurse is caring for a client with severe depression. Which activity is appropriate for this
client?
a. A puzzle
b. Drawing
c. Checkers
d. Paint by number

717. A client experiencing a severe major depressive episode is unable to address activities of
daily living. Which is the appropriate nursing intervention?
a. feed, bathe, and dress the client as needed until the client can perform these activities
independently
b. offer the client choices and consequences to the failure to comply with the expectation of
maintaining activities of daily living
c. structure of the clients day so that adequate time can be devoted to the clients assuming
responsibility for the activities of daily living
d. have the clients Pierce confront the client about how their non-compliance with addressing
activities of daily living affects the milieu

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718. The nurse is preparing to care for a dying client and several family members are at the client's
bedside.Which therapeutic techniques should the nurse use when communicating with the family?
Select all that apply
a. Discourage reminiscing
b. Make the decisions for the family
c. Encourage expression of feelings, concerns and fears
d. Explain everything that is happening to all family members
e. Extended touch and hold the client or family members hand if appropriate
f. Be honest and truthful, and let the client and family know that you will not abandon them.

719. The nurse is assisting with planning the care of a client being admitted to the nursing unit
who has attempted suicide. Which priority nursing intervention should the nurse include in the plan
of care?
a. one to one suicide precautions
b. suicide precautions with 30-minute checks
c. checking the whereabouts of the client every 15 minutes
d. asking that the client to report Suicidal Thoughts immediately

720. The nurse is reviewing the health care record of a client admitted to the psychiatric unit. The
nurse notes that the admission nurse has documented that the client is experiencing anxiety as a
result of a situational crisis. The nurse should determine that this type of Crisis could be caused by
which event?
a. witnessing a murder
b. the death of a loved one
c. a fire that destroyed the client's home
d. a recent rape episode experienced by the client

721. The nurse is gathering data from a client in crisis. When determining the client's perception
of the precipitating event that led to the crisis, which is the most appropriate question to ask?
a. With whom do you live?
b. Who is available to help you?
c. What leads you to seek help now?
d. What do you usually do to feel better?

722. The nurse is assisting with creating a plan of care for the client in a crisis State. When
developing the plan, the nurse should consider which about a Crisis response?
a. a crisis state indicates of the individual is suffering from a mental illness
b. a crisis State indicates that the individual is suffering from an emotional illness
c. presenting symptoms in a crisis situation or similar for all individuals experiencing a crisis
d. a client's response to a crisis is individualized, and what constitutes a crisis for one person
may not constitute a crisis for another person

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723. The nurse observes that a client with a potential for violence is agitated, pacing up and down
in the hallway, and making aggressive and belligerent gestures to other clients. Which statement is
appropriate to make to this client?
a. You need to stop that behaviour now!
b. You will need to be placed in seclusion!
c. What is causing you to become agitated?
d. You will need to be restrained if you do not change your behaviour

724. During a conversation with a depressed client on a psychiatric unit, the client says to the
nurse, “ my family would be better off without me” the nurse should make which therapeutic
response to the client?
a. Have you talked to your family about this?
b. everyone feels this way when they are depressed
c. you will feel better once your medication begins to work
d. you sound very upset are you thinking of hurting yourself?

725. An older client is a victim of elder abuse, and the client's family has been attending weekly
counselling sessions. Which statement by the abusive family member indicates that he or she has
learned positive coping skills?
a. I will be more careful to make sure that my father's needs are met
b. Now that my father is moving into my home, I will need to change my ways
c. I feel better able to care for my father now that I know where to obtain assistance
d. I am so sorry and embarrassed that the abuse event occurred it won't happen again

726. A hospitalized client is taking clozapine for treatment of a schizophrenic disorder. Which
laboratory study prescribed for the client should the nurse specifically review to monitor for an
adverse effect associated with the use of this medication?
a. platelet count
b. cholesterol level
c. white blood cell count
d. blood urea nitrogen level

727. Disulfiram is prescribed for a client in the nurse, is collecting data on the client and is
reinforcing instructions regarding the use of this medication. Which is most important for the nurse
to determine before administration of this medication?
a. a history of hypothyroidism
b. a history of diabetes insipidus
c. when the last full meal was consumed
d. when the last alcoholic drink was consumed

728. The nurse is collecting data from a client and the client's post reports that the client is taking
donepezil hydrochloride. Which disorder should the nurse's fact that this client may have based on
the use of this medication?
a. Dementia
b. Schizophrenia
c. Seizure disorder
d. Obsessive compulsive disorder

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729. Fluoxetine is prescribed, and the nurse reinforces instructions to the client regarding the
administration of the medication. Which statement by the client indicates an understanding about the
administration of this medication?
a. I should take the medication with my evening meal
b. I should take the medication at noon with an antacid
c. I should take the medication in the morning when I first arrived
d. I should take the medication right before bedtime with a snack

730. A client receiving tricyclic antidepressants arrives at the mental health clinic. Which
observation indicates that the client is correctly following the medication plan?
a. reports and not going to work for the past week
b. complains of not being able to “do anything” anymore
c. arrives at the clinic neat and appropriate in appearance
d. report sleeping 12 hours per night in 3 to 4 hours during the day

731. A hospitalized client is prescribed phenelzine sulphate for the treatment of depression. The
nurse reinforces instructions to the client and tells the client to avoid consuming which foods while
taking this medication? Select all that apply
a. Figs
b. Yogurt
c. Crackers
d. Aged cheese
e. Tossed salad
f. Oatmeal cookies

732. A client taking buspirone for 1 month returns to the clinic for a follow-up visit. Which should
indicate medication effectiveness?
a. no rapid heartbeat or anxiety
b. no paranoid thought processes
c. no thought broadcasting or delusions
d. no reports of alcohol withdrawal symptoms

733. A client taking lithium carbonate reports vomiting, abdominal pain, diarrhea, blurred vision,
tinnitus, and Tremors. The lithium level is checked as a part of the routine follow-up, and the level is
3.0 mEq/L (3.0mmol/L). the nurse knows that this is which level?
a. Toxic
b. Normal
c. Slightly above normal
d. Excessively below Normal

734. A client arrives at the health clinic and tells the nurse that they have been doubling their daily
dose of bupropion hydrochloride to help him get better faster. The nurse understands the client is
now at risk for which problem?
a. Insomnia
b. Weight gain
c. Seizure activity
d. Orthostatic hypotension

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735. The nurse is performing a follow-up teaching session with a client discharged one month ago
who is taking Fluoxetine. Which information should be important for the nurse to gather regarding
the adverse effects related to the medication?
a. cardiovascular symptoms
b. gastrointestinal dysfunctions
c. problems with mouth dryness
d. problems with excessive sweating

736. The nurse reinforces homecare instructions to the parents of a child hospitalized with
pertussis. The child is in the convalescent stage and is being prepared for discharge. Which statement
by the parents indicates a need for further teaching?
a. “We need to encourage adequate fluid intake”
b. “Coughing spells may be triggered by dust or smoke”
c. “We need to maintain respiratory precautions and a quiet environment for at least 2 weeks”
d. “Good hand-washing techniques need to be instituted to prevent spreading the disease to
others”

737. A client enters the emergency department confused, twitching, and having seizures. Upon
assessment, flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor is
noted. the serum sodium level is 172mEq/L (172 mmol/L).Which interventions should the primary
health care provider likely prescribed.? . Select all that apply.
a. Monitor vital signs
b. Monitor intake and output
c. Increase water intake only
d. Monitor electrolyte levels
e. Provide a sodium reduced diet
f. Administer sodium replacements

738. The nurse is monitoring a client receiving Glipizide. Which outcome indicates an ineffective
response from medication?
a. A decrease in polyuria
b. A decrease in polyphagia
c. A glycosylated hemoglobin level of 12%
d. A fasting plasma glucose of 100mg/dL (5.7 mmol/L)

739. The nurse is reinforcing discharge instructions to a client receiving sulfisoxazole. Which
should be included in the plan of care for instructions?
a. Maintain high fluid intake
b. Discontinue the medication when feeling better
c. If the urine turns dark brown, call the primary health care provider immediately
d. Decrease the dosage when symptoms are improving to prevent an allergic response

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740. Before administering an intermittent tube feeding through a nasogastric tube, the nurse
checks for gastric residual volume. Which is the best rationale for checking gastric residual value
before administering the tube-feeding?
a. Observe the digestion of formula
b. Check fluid and electrolyte status
c. Evaluate absorption of the last feeding
d. Confirm proper nasogastric tube placement

741. A postoperative client requests medication for flatulence (gas pains). Which medication from
the PRN list should the nurse administer to this client?
a. Ondansteron
b. Simethicone
c. Acetaminophen
d. Magnesium hydroxide

742. A client is admitted to the hospital with a diagnosis of major depression. During the
admission interview, the nurse determines that a major concern is the client’s poor nutritional intake.
Which nursing intervention related to poor nutrition should be the initial choice?
a. Weigh the client three times per week, before breakfast
b. Explain to the client the importance of a good nutritional intake
c. Report the nutritional concern to thePsychiatrist and obtain a nutritional consult as soon as
possible
d. Offer the client several small frequent meals daily and schedule brief nursing interactions
with the client during these times

743. A client received 20 units of NPH insulin subcutaneously at 8 a.m. the nurse to check the
client for a potential hypoglycemic reaction at which time?
a. 9:00 am
b. 12:00 Noon
c. 1:00 pm
d. 5:00 pm

744. The nurse assists with creating a plan of care for a client with hyperparathyroidism receiving
calcitonin-human. Which outcome has the highest priority?
a. Relief of pain
b. Absence of side effects
c. Reaching normal serum calcium levels
d. Verbalization of appropriate medication knowledge

745. The nurse is explaining causes and reasons of hemophilia ATo the parents of a child with the
disease. The nurse should make which statement about hemophilia A.
a. “Hemophilia A is a Y-linked hereditary disease”
b. “Hemophilia A results from a deficiency of factor IX”
c. “Hemophilia A results from a deficiency of factor VIII”
d. “Hemophilia A is always inherited in a recessive manner”

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746. A four-year-old child is admitted to the hospital with suspected acute lymphocytic leukaemia
(ALL) . The nurse should prepare which diagnostic study that can confirm this diagnosis?
a. A platelet count
b. A lumbar puncture
c. A bone marrow biopsy
d. A white blood cell (WBC) count

747. A child with leukaemia is experiencing nausea related to medication therapy. The nurse,
concerned about the child's nutritional status, should offer which items during an episode of nausea?
a. Low-calorie foods
b. Cool, clear fluids
c. Low-protein foods
d. The child's favourite foods

748. To ensure a safe environment for a child admitted to the hospital for a craniotomy to remove
a brain tumour, the nurse should include which in the plan of care?
a. Initiating seizure precautions
b. Using a wheelchair for out-of-bed activities
c. assisting the child with ambulation at all times
d. Avoiding contact with the other children in the nursing unit.

749. The nurse is preparing to suction an adult client through the client's tracheostomy tube.
Which intervention should the nurse perform for this procedure? Select all that apply
a. Apply suction for up to 10 seconds
b. Hyperoxygenate the client before suctioning
c. Set the wall unit pressure at 160 mm Hg
d. Apply suction while gently inserting the catheter
e. Apply intermittent suction while rotating and withdrawing the catheter

750. The nurse is assisting with caring for a client who has a placenta previa. The nurse
understands that a cervical examination should all be performed on the client primarily because it
could have which consequence?
a. Cause hemorrhage
b. Initiate premature labour
c. Rupture fetal membranes
d. Increase chance of infection

751. A mother is breastfeeding her newborn. The mother complains to the nurse that she is
experiencing severe nipple soreness. The nurse should provide which suggestion to the client?
a. Avoid rotating breastfeeding positions so that the nipple will toughen
b. Stop nursing the period of the nipple soreness to allow the nipples to heal
c. Nurse the newborn infant less frequently and substitute bottle feeding until the nipples
become less sore
d. Position the newborn infant with the ear, shoulder and hip in straight alignment and with the
baby’s stomach against the mothers

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752. During the data collection, which behaviour should the nurse expect a client diagnosed with
agoraphobia to describe?
a. Fear of leaving the house
b. Fear of riding elevators
c. Fear of speaking in public
d. A fear of uncleanliness and the need to bathe every hour

753. The nurse checks the food on a tray delivered for an Orthodox Jewish client and notes that
the client has received a cheeseburger and potato fries with whole milk as a beverage. Which action
should the nurse take?
a. Deliver the food tray to the client
b. Replace the whole milk with lactose-free milk
c. Call the dietary department and ask for a different meal
d. Ask the dietary department to replace the beef with pork.

754. A client is brought to the emergency department by the ambulance team after collapse at
home. Cardiopulmonary resuscitation is attempted but unsuccessful. The wife of the client tells the
nurse that the client is an organ donor and that their eyes are to be donated. Which action should the
nurse take next?
a. Place dry, sterile dressings over the eyes of the deceased
b. Call the national donor Association to confirm that the client is a donor
c. Close the eyes, Elevate the head of the bed, and plays a small ice pack on the eyes
d. Ask the wife to obtain the legal documents regarding organ donation from the lawyer

755. The nurse prepares to administer a prescribed dose of Scopolamine. The nurse should
monitor for which side effect of this medication?
a. Dry mouth
b. Diaphoresis
c. Excessive urination
d. Pupillary constriction

756. The nurse is caring for a newborn diagnosed with Down Syndrome. The parents are asking
questions about the disorder. The nurse should provide which information when discussing Down
syndrome?
a. the condition is characterized by above-average intellectual functioning with deficits in
adaptive Behavior
b. the condition is characterized by average intellectual functioning in the absence of deficits in
adaptive Behavior
c. the condition is characterized by sub-average intellectual functioning with the absence of
deficits in adaptive Behavior
d. the condition is congenital and results in moderate to severe retardation and has been linked
to an extra chromosome 21 (group G)

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757. A client with a diagnosis of major depression becomes more anxious, reports sleeping poorly,
and seems to display increased anger the nurse should make which interpretation about the client's
Behavior?
a. the client is at increased risk for suicide
b. the client is dealing with pertinent issues
c. the client may need some time off the unit
d. the client is responding normally to hospitalization

758. Which electrocardiogram changes would the nurse note on the cardiac monitor with a client
whose potassium level 2.7 mEq/L (2.7 mmol/L)?
a. U waves
b. Fat P waves
c. Elevated T waves
d. Prolonged PR interval

759. An adult client with hepatic encephalopathy has a serum ammonia level of 120mcg/dL
(72mcmol/L) and receives treatment with lactulose syrup. The nurse determines that the client has
the best response if the level changes to which after medication administration?
a. 2 mcg/dL (1.2 mcmol/L)
b. 5 mcg/dL (3 mcmol/L)
c. 70 mcg/dL (42 mcmol/L )
d. 100 mcg/dL (60 mcmol/L)

760. The nurse assists with developing a plan of care for the child with meningitis which should be
the priority client problem for a child with a meningitis diagnosis?
a. Pain
b. Inadequate knowledge
c. Neurological dysfunction
d. Difficult family coping process

761. The nurse is caring for a postoperative client who has been NPO and the primary health care
provider has prescribed a clear liquid diet. When planning to initiate this diet, which priority item
should the nurse place at the client's bedside?
a. A straw
b. Code cart
c. Blood pressure cuff
d. Suction equipment

762. The nurse reinforces client instructions about ethambutol. the nurse determines that the client
understands the instructions if the client indicates to report which occurrence?
a. impaired sense of hearing
b. distressing gastrointestinal side effects
c. orange red discoloration of body secretions
d. difficulty discriminating the colour red from green

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763. The nurse is caring for an older client with a diagnosis of myasthenia gravis and has
reinforced self care instructions. Which statement by the client indicates a need for further teaching?
a. “I rest each afternoon after my walk”
b. “I cough and deep breathe many times during the day”
c. “if I get abdominal cramps and diarrhea, I should call my doctor”
d. “I can change the time of my medications on the mornings that I feel strong”

764. The nurse should Implement which in the care of a child who is having a seizure? Select all
that apply
a. Time the seizure
b. Restrain the child
c. Stay with the child
d. Insert an oral Airway
e. Place the child in a Supine position
f. Loosen clothing around the child's neck

765. The nurse is preparing to administer 35 mg. They prescribed an intramuscular dose of
medication to a client. The medication label reads 50 mg/mL. how many millilitres should the nurse
administer to the client? Fill in the blank
Answer_____________________ mL

766. The nurse is calculating a client's 24-hour fluid intake. The client consumed coffee 8 oz, and
orange juice 6 oz for breakfast; soup 4 oz and iced tea 8 oz for lunch; and milk 10 oz, Tea 8 oz, and
water 8 oz for dinner. the client also consumed 24 oz of water during the day. How many millilitres
of fluid did the client consume in the 24-hour period? Fill in the blank.
Answer _____________________ mL

767. A client with diabetes mellitus who has been controlled with daily insulin has been placed on
atenolol for the control of angina pectoris. Because of the effects of Atenolol, the nurse determines
that which is the most reliable indicator of hypoglycemia?
a. Sweating
b. Tachycardia
c. Nervousness
d. Low blood glucose level

768. The nurse is asked to regulate the flow rate of an intravenous solution being administered to a
client. The IV bag contains 50 mL of solution and the solution is to be administered over 30 minutes.
The administration set has a drop factor of 10 gtts/mL. The nurse should regulate the roller clamp on
the infusion set to deliver how many drops per minute? Fill in the blank. Round answer to the nearest
whole number
Answer___________________ gtts/min

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769. Which data would indicate a potential complication associated with age-related changes in
the musculoskeletal system?
a. decrease in height
b. overall sclerotic lesions
c. diminished lean body mass
d. change in structural bone tissue

770. The nurse reinforces home care instructions to the mother of a child recovering from Reye’s
syndrome. Which statement by the mother indicates a need for further teaching?
a. I need to check for jaundiced eyes and skin everyday
b. I need to have my child nap during the day to provide rest
c. I need to decrease the stimuli at home to prevent intracranial pressure
d. I need to give frequent small nutritious meals if my child starts to vomit

771. A primary healthcare provider prescribes potassium chloride elixir, 20mEq orally daily. The
medication label states potassium chloride, 30 mEq/15 mL. How many millimetres should the nurse
prepare to administer the dose? Fill in the blank
Answer______________mL

772. The nurse reinforces medication instructions to a client with peptic ulcer disease. Which
statement by the client indicates the best understanding of the medication therapy?
a. Antacids will coat my stomach
b. Omeprazole will coat the ulcer and help it heal
c. Sucralfate will change the fluid in my stomach
d. The nizatidine will cause me to produce less stomach acid

773. In planning activities for the depressed client, especially during the early stage of
hospitalization, which action is best?
a. Plan nothing until the client asked to participate in the milieu
b. Encourage the client to participate in a structured daily program of activities
c. Give the client a menu of daily activities and insist that the client participate in all activities
d. Provide an activity that is quiet in solitary in nature to avoid increased fatigue, such as
drawing or reading a book

774. The nurse is assisting with preparing a plan of care for a four year old child hospitalized with
nephrotic syndrome. Which intervention is most appropriate for this child?
a. Provide a high-salt diet
b. Provide a high protein diet
c. Discourage visitors at mealtimes
d. Encourage the child to eat in the playroom

775. The nursing instructor asks a student to describe the pathophysiology that occurs in Cushing's
Disease. Which statement by the student indicates an accurate understanding of this disorder?
a. Cushing's disease is characterized by an oversecretion of insulin
b. Cushing's disease is characterized by an oversecretion of glucocorticoid hormones
c. Cushing's disease is characterized by an under secretion of corticotropic hormones
d. Cushing's disease is characterized by under secretion of glucocorticoid hormones

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776. The nursing instructor asks a nursing student about the physiology related to the cessation of
ovulation that occurs during pregnancy. Which response by the student indicates an understanding of
this physiological process?
a. ovulation Caesars during pregnancy because the circulating levels of estrogen and
progesterone are high
b. ovulation seizes during pregnancy because of circulating levels of estrogen and progesterone
are low
c. the low levels of estrogen and progesterone increase the release of follicle-stimulating
hormone and luteinizing hormone
d. the high levels of estrogen and progesterone promote the release of follicle-stimulating
hormone and luteinizing hormone

777. The nurse is assisting with collecting data on a child with seizures. The nurse is interviewing
the child's parents to establish their adjustments to caring for their child with a chronic illness. Which
statement by the parents indicates a need for further teaching?
a. our child sleeps in our bedroom at night
b. we worry about injuries when our child has a seizure
c. our child is involved in swim program with neighbours and Friends
d. our babysitter just completed first aid and child resuscitation training

778. A client is taking Lansoprazole for The Chronic management of zollinger-ellison syndrome.
If prescribed, which medication would be appropriate for the client if needed for a headache?
a. Naprosyn
b. Ibuprofen
c. Acetaminophen
d. Acetylsalicylic acid

779. A depressed client verbalizes feelings of low self-esteem and self-worth typified by
statements such as “I'm such a failure. I can't do anything right!” Which action should the nurse
take?
a. Tell the client that this is not true and that we all have a purpose in life
b. Remain with the client and sit in silence until the client verbalizes feelings
c. Identify recent behaviours or accomplishments that demonstrate skill and ability
d. Reassure the client that you know how the client is feeling and that things will get better

780. The nurse is assigned to care for an infant with cryptorchidism. One testis cannot be palpated.
The nurse anticipates that which diagnostic study will be prescribed to determine where the
undescended testes located in the body?
a. Cystoscopy
b. Abdominal x-ray
c. Urodynamic study
d. Computed tomography scan

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781. The nurse is caring for a client with a diagnosis of pemphigus. The nurse should include
which interventions in the plan of care for the client? Select all that apply
a. Administering prescribed Acyclovir
b. Applying prescribed topical antibiotic
c. Administering prescribed corticosteroid
d. Administering prescribed oral amphotericin B
e. Applying domeboro solution to the affected skin

782. A client asks the nurse about the causes of acne. The nurse should respond by making which
statement to the client?
a. It is caused by oily skin
b. The exact cause of acne is not known
c. It occurs as a result of exposure to heat and humidity
d. Acne is caused by eating chocolate nuts in fatty foods

783. Skin breakdown occurs on a client's hand at the site of an intravenous catheter that had
medication infusing. the nurse determines that which adverse effect occurred? Refer to figure

a. Phlebitis
b. Infiltration
c. Thrombosis
d. Extravasation

784. The nurse is reviewing the health record of a pregnant client at 16 weeks gestation. The nurse
should expect a document that the fundus of the uterus is located in which area?
a. at the umbilicus
b. just above the symphysis pubis
c. at the level of the xiphoid process
d. midway between the symphysis pubis and the umbilicus

785. The nurse is assigned to care for a child with a compound fracture of the arm that occurred as
a result of a fall. The nurse plans care knowing that this type of fracture involves which specific
characteristic
a. the entire bone fracture straight across
b. a greater risk of infection than a simple fracture
c. the bone being fractured but not producing a break in the skin
d. one side of the bone being broken and the other side being bent
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786. The nurse is reinforcing instructions to the parents of an infant with clubfoot about the care of
a plaster cast. Which statements should the nurse include in the instructions? Select all that apply.
a. The cast can be cleansed with a wet cloth on the outside
b. The foot should be kept elevator for the first 24 to 48 hours
c. The cast will dry in 30 minutes so it can be handled after that time
d. Reposition the infant every two to four hours until the cast is Thoroughly dried
e. The edges of the cast can be paddled with small pieces of Moleskine or adhesive tape

787. A client with type 1 diabetes mellitus is to begin an exercise program, and the nurse is
reinforcing instructions to the client regarding the program. Which instructions should the nurse
include?
a. try to exercise before meal time
b. administer insulin after exercising
c. take a blood glucose test before exercising
d. exercise should be performed during peak times of insulin

788. The nurse is caring for an older client who is terminally ill. Which signs indicate to the nurse
that death may be imminent?
a. flushed warm skin
b. eupnea and normal body temperature
c. irregular, noisy breathing and cold, clammy skin
d. presence of swallowing reflex in active bowel sounds

789. The nurse has reinforced instructions to a client with tuberculosis about proper handling and
disposal of respiratory secretions. The nurse determines that the client understands the instructions if
the client verbalizes to take which measure?
a. discard used tissues in a plastic bag
b. wash hands at least four times a day
c. brush teeth and rinse mouth once a day
d. turn head to the side if coughing or sneezing

790. A client who's been taking isoniazid for 1 and 1/2 months complaints the nurse about
numbness, paresthesia, and tingling in extremities the nurse interprets that the client is experiencing
which adverse effect?
a. Hypercalcemia
b. Peripheral neuritis
c. Small blood vessels spasm
d. Impaired peripheral circulation

791. The nurse is preparing a two-year-old child with suspected nephrotic syndrome for a renal
biopsy to confirm the diagnosis. The mother asks the nurse, “will my child ever look thin again?”
The nurse should respond by giving Which statement?
a. do you feel guilty about your child's weight gain
b. in most cases medication and diet will control fluid retention
c. wearing loose-fitting clothing should help conceal the extra weight
d. when children are little it's expected the look a little chubby

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792. The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive
pulmonary disease. Which should the nurse expect to note in the client? Select all that apply.
a. Hypocapnia
b. Dyspnea during exertion
c. Presence of a productive cough
d. Difficulty breathing while talking
e. Increased oxygen saturation with exercise
f. A shortened expiratory phase of respiration

793. Nurse is preparing to administer an enema to an adult client. Which intervention should the
nurse plan to perform for this procedure? Select all that apply.
a. Apply disposable gloves
b. Place the client in the right Sims position
c. Lubricate the enema tube and insert it approximately 4 in
d. Clamp the tubing if the client expresses discomfort during the procedure
e. Hang the enema solution container 24 in above the client anus
f. Ensure that the temperature of the solution is between 100 degrees Fahrenheit (37.8 C) and
105 degrees Fahrenheit (40.5C)

794. The nurse is assigned to care for an adult client who had a stroke and is aphasic. Which
interventions should the nurse use for communicating with the client? Select all that apply
a. face the client when talking
b. speak slowly and maintain eye contact
c. use gestures when talking to enhance words
d. avoid the use of body language when talking to client
e. give the client directions using short phrases in simple terms
f. phrase what was said differently the second time if there is a need to repeat it

795. The nurse observes that a client with a nasogastric tube connected to continuous gastric
suction is mouth breathing, has dry mucous membranes, and has a foul breath holder. When planning
care, which nursing intervention would be best to maintain the Integrity of this client's oral mucosa?
a. offer small sips of water frequently
b. encourage the client to suck on the sour hard candy
c. use lemon glycerin swabs to provide oral hygiene
d. use diluted mouthwash and water to swab the mouth after brushing teeth

796. A client is admitted to the hospital with possible Rheumatic endocarditis. The nurse should
check for history of which type of infection
a. viral infection
b. yeast infection
c. streptococcal infection
d. staphylococcal infection

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797. A client who is taking Hydrochlorothiazide has also been prescribed triamterene. the client
asks why both medications are required which response has the most accurate to give to the client?
a. Both are weak potassium excreting diuretics
b. The combination of these medications prevent renal toxicity
c. Hydrochlorothiazide is an expensive medication, so using a combination of diuretics is cost-
effective
d. Triamterene is a potassium retaining diuretic where is Hydrochlorothiazide is a potassium
excreting diuretic

798. A client who has been taking fosinopril is very distressed, telling the nurse that he cannot
taste food normally since the beginning of the medication two weeks ago. Which suggestion would
provide the best support for the client?
a. Tell the client to not take the medication with food
b. Suggest that the client taper the dose until taste returns to normal
c. Inform the client that impair Chase's is expected in generally disappears in 2 to 3 months
d. Tell the client that a request will be made to the primary healthcare provider to change the
prescription

799. The nurse is planning to administer amlodipine to a client. The nurse should plan to check
which before giving the medication?
a. respiratory rate
b. blood pressure and heart rate
c. heart rate and respiratory rate
d. level of Consciousness and blood pressure

800. A client had an aortic valve replacement 2 days ago. This morning the client tells the nurse “I
don't feel any better than I did before surgery.” Which response by the nurse is most appropriate?
a. You will feel better in a week or two
b. It is only the second day post-op cheer up
c. This is a normal frustration. It'll get better
d. You are concerned that you don't feel any better after surgery?

801. The nurse is preparing a list of home care instructions regarding stoma and laryngectomy care
to a client. Which instruction should be included in the list? Select all that apply.
a. Restrict fluid intake
b. Obtain a Medic Alert bracelet
c. Keep the humidity in the home loan
d. Prevent debris from entering the stoma
e. void exposure to people with infections
f. Avoid swimming and use care when showering

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802. The nurse administers an injection to a client with a diagnosis of acquired immunodeficiency
syndrome (AIDS) after administering the medication the nurse should dispose of the used needles by
which method?
a. asking the client to recap the needle
b. placing the needle and syringe in a puncture-resistant container
c. recapping the needle before placing it in a puncture-resistant container
d. laying the needle and syringe on the bedside table and carefully recapping the needle

803. The nurse is assisting with identifying clients in the community at risk for latex allergy.
Which client population is most at risk for developing this type of allergy?
a. children in daycare centres
b. individuals with spina bifida
c. individuals with cardiac disease
d. individuals living in group homes

804. A client has just had a cast removed in the underlying skin is yellow brown and crusted. The
nurse determines that further instructions are needed about skin care if the client makes which
statement?
a. I will soak the skin and then wash it gently
b. I need to scrub the skin and vigorously with soap and water
c. I need to apply an emollient lotion to enhance softening
d. I need to use a sunscreen on the skin if I will be directly exposed to the Sun

805. A client has had skeletal traction applied to the right leg and has an overhead trapeze
available for use. The nurse should monitor which area as a high-risk area for pressure and
breakdown?
a. scapulae
b. left heel
c. right heel
d. back of the head

806. A client has been placed in Buck's extension traction. Which technique provided by the nurse
will provide countertraction?
a. Using a footboard
b. Providing an overhead trapeze
c. Slightly elevating the foot of the bed
d. Slightly elevating the head of the bed

807. The nurse should expect to note which interventions in the plan of care for a client with
hypothyroidism? select all that apply
a. Provide a cool environment for the client
b. Instruct the client to consume a high-fat diet
c. Instruct the client about thyroid replacement therapy
d. Encourage the client to consume fluids and high fibre foods
e. Inform the client that iodine preparations will be prescribed to treat the disorder
f. Instruct the client to contact the primary health care provider if episodes of chest pain occur

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808. The nurse is admitting a client with Guillain-Barre syndrome to the nursing unit the client has
an ascending paralysis to the level of the waste. Knowing the complications of the disorder, the nurse
should bring which items into the client's room?
a. nebulizer and pulse oximeter
b. blood pressure cuff and flashlight
c. flashlight and incentive spirometer
d. electrocardiographic monitoring electrodes and intubation tray

809. A client with chronic kidney disease is receiving ferrous sulphate. The nurse should monitor
the client for which common side effect associated with this medication
a. Diarrhea
b. Weakness
c. Headache
d. Constipation

810. The nurse is attempting to communicate with a hearing-impaired client. Which strategy by
the nurse would be least helpful when talking to this client?
a. reducing any background noise
b. smiling continuously during the conversation
c. facing the clients so that there is a light on the nurse's face
d. ensuring that showing frustration through facial expression is not done

811. The nurse is preparing to administer digoxin 0.125 mg orally to a client with heart failure.
Which Vital sign is most important for the nurse to check before administering the medication.
a. Heart rate
b. Temperature
c. Respirations
d. Blood pressure

812. A postoperative client has a prescription to receive IV of 1000 ml normal saline solution over
a period of 10 hours. The drop factor for the IV infusion is set at 15 gtts/mL. The nurse says the flow
rate at how many drops per minute? Fill in the blank.
Answer_________________ gtts/min

813. The nurse is preparing to set up a sterile field using the principles of aseptic technique to
perform a dressing change. Which should the nurse include in the preparation? Select all that apply.
a. Use a dry table that is below waist level
b. Open the distal flap of the sterile package first
c. Prepare the sterile field just before the plan procedure
d. Don clean gloves before touching items on the sterile field
e. Place the sterile field one foot behind the working area and out of view of the client
f. Avoid placing items within 1 in of any area surrounding the outer edge of the sterile field

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814. The nurse is performing nasotracheal suctioning of a client. The nurse interprets that the
client is adequately tolerating the procedure if which observation is made?
a. skin colour becomes cyanotic
b. secretions are becoming bloody
c. coughing occurs with suctioning
d. heart rate decreases from 78 bpm to 54 bpm

815. The nurse inspects the oral cavity of a client with cancer and nose white patches on the
mucous membranes. The nurse interprets this occurrence as which outcome?
a. common
b. suggestive of anemia
c. characteristic of a thrush infection
d. indicatives of need to improve oral hygiene

816. The nurse is monitoring the laboratory results of a client preparing to receive chemotherapy.
the nurse determines that the white blood cell count is normal if which result is present?
a. 2000mm3 (2x109/L)
b. 3000mm3 (3x109/L)
c. 50000mm3 (5x109/L)
d. 15,000mm3 (15x109/L)

817. The nurse reinforces instructions to the client about breast self-examination. The nurse
instructs the client to lie down and examine the left breast. Which is the correct area for placing a
pillow when examining the left breast?
a. under the left shoulder
b. under the right scapula
c. under the right shoulder
d. under the small of the back

818. A client is suspected of having an abdominal tumour is scheduled for a computed

tomography scan with dye injection. The nurse should tell the client which information about the
test?
a. the test may be painful
b. fluids will be restricted after the test
c. the test takes approximately two to three hours
d. the dye injected may cause a warm flushing sensation

819. The nurse is caring for a client dying of cancer. During care, the client states, “if I can just
live long enough to attend my daughter's graduation I will be ready to die.” Which phase of coping is
this client experiencing?
a. Anger
b. Denial
c. Bargaining
d. Depression

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820. The nurse is caring for a client who has been prescribed furosemide and is monitoring for
adverse effects associated with this medication. What should the nurse recognize as potential adverse
effects? Select all that apply
a. Nausea
b. Tinnitus
c. Hypotension
d. Hypokalemia
e. Photosensitivity
f. Increase urinary frequency

ALL DONE!!!

WORKING SO HARD

SO PROUD OF YOU

WE’RE ALL GONNA KILL THIS EXAM!!!

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