Sie sind auf Seite 1von 15

1. Nurse Judith Dalingay admitted to the hospital a client after receiving a radium implant for bladder cancer.

Nurse Judith takes which of the following priority actions in the care of this client? a. Encourages the client to take frequent rest periods b. Admits the client to a private room c. Encourages the family to visit d. Places the client on reverse isolation 2. A client is to undergo weekly intravesical chemotherapy for bladder cancer for the next 8 weeks. The nurse interprets that the client understands how to manage the urine as a biohazard if the client states to: a. Disinfect the urine and toilet with bleach for 6 hours following a treatment b. Have one bathroom strictly set aside for the clients use for the next 2 months c. Purchase extra bottles of scented disinfectant for daily bathroom cleansing d. Void into a bedpan and then empty the urine into the toilet 3. A male client who is admitted to the hospital for an unrelated medical problem is diagnosed with urethritis resulting from chlamydial infection. The nursing assistant assigned to the client asks the nurse what measures are necessary to prevent contraction of the infection during care. The nurse tells the assistant that: a. Enteric precautions should be instituted for the client b. Contact isolation should be initiated, since the disease is highly contagious c. Universal precautions are quite sufficient, since the disease is transmitted sexually d. Gloves and mask should be used when in the clients room 4. Mr. Bua-eg is in extreme pain from scrotal swelling that is caused by epididymitis. The nurse administers a subcutaneous narcotic analgesic in the left arm to relieve the pain. Nurse Leo does which of the following actions next? a. Tells the client to do range of motion exercises with the left arm to absorb the medication into the bloodstream b. Checks the name bracelet of the client c. Put the side rails up on bed d. Dims the lights in the room 5. Kagawad a registered nurse is preparing the bedside for a postoperative parathyroidectomy client. He ensures that which piece of medical equipment is at the clients bedside? a. Underwater seal chest drainage b. Tracheotomy set c. Intermittent gastric suction d. Cardiac monitor 6. A client who is scheduled for gallbladder surgery is mentally impaired and is unable to communicate. With regards to obtaining permission for the surgical procedure, which nursing intervention would be most appropriate? a. Ensure that the family has signed the informed consent b. Ensure that the client has signed the informed consent c. Inform the family about the advance directive process d. Inform the family about the process of a living will 7. A nurse is in the process of giving a client a bed bath. In the middle of the procedure, the unit secretary calls the nurse on the intercom to tell the nurse that there is an emergency phone call. The most appropriate nursing action is to: a. Leave the clients door open so that client can be monitored and answer the phone call b. Finish the bath before answering the phone call c. Immediately walk out off the clients room and answer the phone call d. Cover the client, place the call light within reach, and answer the phone call

8. A nursing manager is reviewing the purpose for applying restraints with the nursing staff. The nurse manager tells the staff that which of the following is not an indication for the use of a restraint? a. To prevent falls b. To restrict movement of a limb c. To prevent the client from pulling out IV lines and catheters d. To prevent the violent client from injuring self and others 9. A nursing assistant is caring for an elderly client with cystitis who has an indwelling urinary catheter. The registered nurse provides directions regarding care and ensures that the nursing assistant: a. Uses soap and water to cleanse the perineal area b. Keeps the drainage bag above the level of the bladder c. Loops the tubing under the clients leg d. Lets the drainage tubing rest under the leg 10. A nurse is assigned to care for a woman with preeclampsia. The nurse plans to initiate which action to provide a safe environment? a. Turn off room lights and draw the window shades b. Maintain fluid and sodium restrictions c. Take the vital signs every four hours d. Encourage visits from family and friends for psychosocial support 11. A nurse has given a subcutaneous injection to the client with acquired immunodeficiency syndrome (AIDS). The nurse disposes of the used needle and syringe by: a. Placing the uncapped needle and syringe in a labeled, rigid plastic container b. Recapping the needle and discarding the syringe in the disposal unit c. Breaking the needle before discarding it d. Placing the uncapped needle and syringe in a labeled cardboard box 12. A nurse is planning care for a client with acute glomerulonephritis. The nurse instructs the nursing assistant to do which of the following in the care of the client? a. Monitor the temperature every two hours b. Remove the water pitcher from the bedside c. Ambulate the client frequently d. Encourage a diet that is high in protein 13. A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed room. A newly admitted client will be assigned to this clients room. Which client would be inappropriate to assign to this twobed room? a. A client with pneumonia b. A client with a fractured leg that is casted c. A client who can care for self d. A client who is scheduled for a diagnostic test 14. A nurse is assisting at a code and the physician is going to defibrillate the client. Of the following items, which is the only one that the nurse does not need to remove from the bedside just before the client is defibrillated? a. Backboard b. Oxygen c. Nitroglycerin patch d. Ventilator 15. A nurse has an order to get a client out of bed to a chair on the first postoperative day following total knee replacement (TKR). The nurse plans to do which of the following to protect the knee joint? a. Apply a knee immobilizer before getting the client up, and elevate the clients surgical leg while sitting

b. Apply a compression dressing, and put ice on the knee while sitting c. Lift the client to the bedside chair leaving the continuous passive motion (CPM) machine in place d. Obtain a walker to minimize weight bearing by the client on the affected leg 16. A nurse is caring for client immediately following a bronchoscopy. The client received intravenous sedation and a topical anesthetic for the procedure. In order to provide a safe environment for the client at this time, the nurse plans to: a. Place a padded tongue blade at the bedside in case of a seizure b. Check the bedside to ensure no food or fluid is within the clients reach to prevent aspiration c. Connect the client to a bedside ECG to monitor for dysrhythmias d. Place a water-seal chest drainage set at the bedside in case of pneumothorax 17. A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing the client, the first nursing action would be to A) Administer pain medication B) Suction excessive tracheobronchial secretions C) Assist client to turn, deep breathe and cought D) Monitor oxygen saturation 18. An elderly client is being admitted to same0day surgery for cataract extraction. The client has several diamond rings. The nurse should explain to the client that. a. her rings will be taped before the surgery b. she will sign a valuable envelope that will be placed in a safe c. the rings will be locked in the narcotics box d. the nursing supervisor will hold onto the rings before the surgery 19. A 22 year-old client is bought to the emergency department with his fiancee' after being involved in a serious motor vehicle accident. His Glasgow Coma Scale is 7 and he demonstrates evidence of decortate posturing. Which of the following would be appropriate for obtaining a permit to place a catheter for intracranial pressure (ICP) monitoring? a. the nurse will obtain a signed consent from the client's fiancee because he is of legal age and they are engaged to be married. b. the physician will get a consultation from one other physician and proceed with placement if the ICP catheter until the family arrives to sign the consent. c. two nurses will receive a verbal consent by telephone from the client's condition next of kin before inserting the catheter d. the physician will document the emergency nature of the client's condition and that an ICP catheter for monitoring was placed without a consent 20. Assessment of the client taking lithium reveals dry mouth, nausea, thirst and mild hand tremor. Based on an analysis of these findings, which of the following will the nurse do next? a. hold the lithium and obtain a stat lithium level to determine therapeutic effectiveness b. continue the lithium and immediately notify c. continue the lithium and reassure the client that these temporary side effects will subside d. hold the lithium and monitor the client for signs and symptoms of increasing toxicity 21. An expected psychologic response to a low potasium level is a. cardiac dysrhythmias b. hyperglycemia c. hypertension

d. increased energy 22. A client in a cardiac rehabilitation program states that he would like to make sure he is eating the right foods to ensure adequate endurance on the treadmill. Which of the following nutrients is most helpful for promoting endurance during sustained activity? a. protein b. carbohydrate c. fat d. water 23. A female client is admitted with complaints of fatigue, cold intolerance, weight gain, and muscle weakness. The initial nursing assessment reveals brittle nails, dry hair, constipation, and possible goiter. The client is most likely experiencing signs and symptoms of a. cushing's disease b. hypothyroidism c. hyperthryroidism d. a pituitary tumor 24. The nurse is preparing a discharge plan for a 16-year-old who as fractured her femur and ulna. The client asks the nurse how quickly her fractures will heal so she can return to her normal activities. Which of the following responses would be most appropriate for the nurse to make? a. the healing of your leg will be delayed because you have had a skeletal traction. b. it will take your arm about 12 weeks to heal completely, but it will take your leg about 24 weeks. c. because you are young and healthy, your bones should heal in less than 12 weeks. d. you will require long-term rehabilitation and should expect it to take at least 8 months for your bones to heal. 25. The nurse assesses the assigned clients for the shift. Of the following assigned clients, which client is at greatest risk for falling? a. a 25-year-old man with three fractured ribs and a fractured left arm b. a 70-year-old woman with episodes of syncope c. a 50-year-old man with angina d. a 30-year-old woman with a fractured ankle 26. The nurse is developing an education plan for clients with hypertension. Which of the following long-term goals would it be most appropriate for the nurse to emphasize to the clients? a. develop a plan to limit stress b. participate in a weight reduction program c. commit to lifelong therapy d. monitor blood pressure regularly 27. An obese diabetic client complains of bilateral leg aching. His physician has referred him to cardiac rehabilitation to start an exercise program. Which of the following activities would be most helpful for the client? a. interval training on the stationary bicycle b. interval training on the treadmill c. interval training on a commercial ski machine d. interval training on the stair climber

28. Which of the following interventions is recommended protocol for all clients who are at risk for pressure sore development? a. identify at-risk clients on admission to the health care facility b. placed at-risk clients on an every 2-hour turning schedule c. automatically place clients in specialty beds d. provide at-risk clients with high-protein, high carbohydrate diet 29.A client with myasthenia gravis is seen in the emergency department for epistaxis. A priority nursing diagnosis would be a. ineffective breathing pattern b. risk for aspiration c. risk for injury d. self-care deficit 30. Which of the following measures should be implemented promptly after a client's nasogastric tube has been removed? a. provide the client with oral hygiene b. offer the client liquids to drink c. encourage client to cough and deep breath d. auscultate the client's bowel sounds 31. When administering phenytoin (Dilantin) to a child, the nurse should be aware that a toxic effect of phenytoin therapy is: a. Stephens-Johnson syndrome b. Folate deficiency c. Leukopenic aplastic anemia d. Granulocytosis and nephrosis 32. A nurse is assessing a client with a diagnosis of goiter. Which of the following would the nurse expect to note during the assessment of the client? a. Client complaints of slow wound healing b. Client complaints of chronic fatigue c. An enlarged thyroid gland d. The presence of heart damage 33. Lindane (Kwell) is prescribed for the treatment of scabies. A nurse reviews the client's record, knowing that the medication therapy is contraindicated if the client is: a. A 42-year-old female b. An elderly client c. A 6-year-old child d. A 52-year-old male with hypertension 34. A registered nurse (RN) is planning assignments for the clients on a nursing unit. The RN needs to assign four clients and has a registered nurse, a licensed practical (vocational) nurse, and two nursing assistants on a nursing team. Which of the following clients would the nurse most appropriately assign to the licensed practical (vocational) nurse? a. A client who requires a 24-hour urine collection b. An elderly client requiring assistance with a bed bath and frequent ambulation c. A client on a mechanical ventilator who requires frequent assessment and suctioning d. A client with an abdominal wound requiring wound irrigations and dressing changes every 3 hours

35. A client is seen in a clinic for complaints of thirst, frequent urination, and headaches. Following diagnostic studies, diabetes insipidus in diag nosed. Lypressin (Diapid) is prescribed. A nurse instructs the client that the medication is pre scribed to: a. Relieve the headaches b. Increase water reabsorption c. Decrease the production of the antidiuretic hormone d. Stimulate the production of aldosterone 36. A young male client with type 1 diabetes mellitus tells a nurse that he might lose his job because he has been having frequent hypoglycemic reactions. His boss thinks that he is drunk during these episodes, and that he has been drinking on the job. Which action by the nurse would best assist this client to meet his needs? a. Contact the local employment office to help him find another job b. Ask the client if he indeed has been drinking at work c. Examine factors with the client that may be causing frequent hypoglycemic episodes d. Ask the client what he does to treat his hypoglycemia 37. A nurse in a newborn nursery is assessing a neonate who was born of a mother addicted to cocaine. Which of the following would the nurse not expect to note in the neonate? a. Tremors b. Bradycardia c. Irritability d. Hypertension 38. A client with pheochromocytoma is scheduled for surgery and says to the nurse, "I'm not sure that s u rg ery i s t he be st t hin g to do ." Th e m o st appropriate response by the nurse is which of the following? a. "You have concerns about the surgical treatment for your condition?" b. "There is no reason to worry. Your doctor is a wonderful surgeon." c. "You are very ill. Your physician has made the correct decision." d. "I think you are making the right decision to have the surgery." 39. A client seen in a health care clinic is diagnosed with mild anemia, The anemia is believed to be a result of the menstrual period. The woman asks a nurse how much blood is lost during a menstrual period. The nurse plans to base the response on which of the following amounts of blood lost during this time? a. 40 mL b. 60 mL c. 80 mL d. 100 mL 40. A nurse is preparing to discontinue a client's nasogastric (NG) tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse makes which statement to the client? a. ''Take a deep breath when I tell you and breathe normally while I remove the tube." b. "Take a deep breath when I tell you and bear down while I remove the tube." c. "Take a deep breath when I tell you and slowly exhale while I remove the tube." d. "Take a deep breath when I tell you and hold it while I remove the tube." 41. A depressed client is found unconscious on the floor in the day room. A nurse finds several empty bottles of a prescribed tricyclic antidepressant lying near the client. The immediate action of the nurse is to: a. Call a "Code," as this incident presents a medical emergency

b. Induce vomiting and contact the physician for further orders c. Call the Poison Control Center d. Try to figure out the number of pills taken 42. A client is returned to the nursing unit with chest tubes in place after thoracic surgery. During the first few hours postoperatively, the nurse assesses for drainage and expects to note that it is: a. Serous b. Serosanguineous c. Bloody d. Bloody with frequent small clots 43. A nurse is assessing a patient for discharge to a residential treatment center. To which of the following factors should a nurse give highest priority? a. Family history of mental illness c. Individual strengths b. Developmental history d. Social support systems 44. A patient in an ambulatory care center is suspected of having an acoustic neuroma. Which of the following findings, if identified in the patient, would support this diagnosis? a. Diplopia b. dysphagia c. Tinnitus d. Ataxia

45. A young boy, who is receiving chemotherapy, develops alopecia and says to the nurse, Im so ugly. Ive lost all my hair. Which of the following responses would be appropriate for the nurse to make to the child? a. Did you know that because your hair fell out, we know that the medicine is working to make you better? b. Would you like to see some pictures of famous men who are bald? c. Its hard to look different from the way you used to look. d. You can wear a baseball cap until your hair grows back. 46. A patient is receiving neuroleptic medication. The nurse should assess the patient for symptoms of an acute dystonic reaction, which include a. Intention tremors b. ataxic gait c. difficulty swallowing d. psychomotor agitation

47. D. Psychomotor agitation is a symptom of akathisia, a side effect of antipsychotic medications. Which of the following mental health problems is commonly associated with severe, chronic medical disorders? a. Anxiety b. Depression c. Labile affect d. Confusion 48. It is suspected that a patient who comes to the ambulatory care center reporting a sore throat has mononucleosis. Which of the following additional findings, if noted by the nurse, would support this diagnosis? a. White patches on the tongue c. Periorbital edema b. Periorbital edema d. Productive cough 49. Which of the following statements, if made by a patient who has diabetes mellitus, would understanding of teaching on diabetes and alcohol A. Alcohol may be taken in moderate amounts w/ my meals. B. Alcohol will cause an increase in my blood sugar. C. Alcohol will decreased my susceptibility to infections. D. Alcohol intake will cause a decreased need for insulin. indicate an

50. An obese adolescent is seen in the health clinic for a routine examination. The patient expresses a desire to begin a weight reduction plan. Which of the following statements would indicate to the nurse that the child is motivated to lose weight? A. I am just too fat and clumsy. B. I feel tired and am not interested in my school work. C. I often sit home and read or watch television. D. I like to walk and visit with my friends. 51. The nurse is preparing a teaching plan for a 45-year-old client recently diagnosed with type 2 diabetes mellitus. What is the first step in this process? a. establish goals b. choose video materials and brochures c. asses the client's learning needs d. set priorities of learning needs 52. The nurse would assess the client with severe diarrhea for which of acid-base imbalance? a. respiratory acidosis b. respiratory alkalosis c. metabolic acidosis d. metabolic alkalosis 53. Which of the following factors is most important for healing of an infected decubitus ulcer? a. adequate circulatory status b. scheduled periods of rest c. balanced nutritional diet d. Fluid intake of 1500 mL/day

54. Which of the following nursing diagnoses would the nurse identify as a priority after surgical repair of a cleft lip? a. pain b. risk for infection c. impaired physical mobility d. impaired parenting 55. Which of the following findings would the nurse most likely note in the client who is in the compensatory stage of shock? a. decreased urinary output b. significant hypotension c. tachycardia d. mental confusion 56. A client with liver cancer who is receiving chemotherapy tells a nurse that some foods on the meal tray taste bitter. The nurse would try to limit which of the following foods that are most likely to cause this taste for the client? a. Beef b. Potatoes c. Custard

d. Cantaloupe 57. A nursing student is asked to describe the corpus of the uterus. Which of the following responses, if made by the student, indicates an understanding of the anatomy of the uterus? a. It is the lower portion of the uterus. b. "It is the uppermost part of the uterus." c. "It is the area where the cervix meets the external os." d. "It is the area where the vagina meets the uterus." 58. Octreotide acetate (Sandostatin) is prescribed for a client with acromegaly. A nurse monitors the client, knowing that which side effect is associated with the administration of this medication? e. Constipation f. Polyuria g. Abdominal pain h. Hypotension 59. Cortisone acetate (Cortone Acetate) is prescribed for a client with adrenal insufficiency. A nurse provides instructions to the client regarding the medication. Which statement,if made by the client, indicates a need for further instruction? a. "I will eat a good breakfast every day." b. "I will avoid people with colds." c. "I will limit my sodium intake." d. "I will stop the medication when I feel better." 60. The client who suffered a crush injury to the leg has a highly positive urine myologbin level. The nurse assess this particular client carefully to signs of a. Cerebrovascular accident c. Respiratory failure b. Acute tubular necrosis d. Myocardial infarction 61. A client who has a gastrostomy tube for feeding refuses to participate in the plan of care, will not make eye contact, and does not speak to the family or visitors. The nurse assesses that this client is using which type of coping mechanism? a. Self-control c. Accepting responsibility b. Problem-solving d. Distancing 62. The nurse is instructing a postpartum client with endometritis about preventing the spread of infection to the newborn infant. The nurse would tell the client that a. Hands should be washed thoroughly before holding the infant b. The newborn infant will not be allowed in the mothers room at all c. There is no danger of the newborn contracting the disease d. Visitors are not allowed to hold the baby 63. The nurse is caring for a client with possible cholelithiasis who is being prepared for an intravenous cholangiogram, and the nurse teaches the client about the procedure. Which client statement indicates that the client understands the purpose of this test? a. They are going to look at my gallbladder and ducts. b. This procedure will drain my gallbladder c. My gallbladder will be irrigated d. They will put medication in my gallbladder

64. The nurse has given discharge instructions to the client who has underwent vein ligation and stripping early in the day. The nurse evaluates that the client understands activity and positioning limitations if the client states that it is most appropriate to a. Lie down with the legs elevated and avoid sitting b. Cross the legs at the ankle only, but not at the knee c. Sit in the chair 3 times a day 3 hours at a time d. Walk upright for as much as possible each day 65. The client is about to undergo a lumbar puncture. The nurse describes to the client that which of the following positions will be used during the procedure? e. Side-lying with the legs pulled up and the head bent down onto the chest f. Side-lying with a pillow under the hip g. Prone with a pillow under the abdomen h. Prone in slight Trendelenburgs position 66. The nurse is preparing to care for a client who has undergone a myelogram using a oil-based contrast agent. The nurse plans to position the client on bed rest for a. 6 to 8 hours with the head of bed flat b. 6 to 8 hours with the head of bed elevated 15 to 30 degrees c. 2 to 4 hours with the head of bed flat d. 2 to 4 hours with the head of bed elevated 15 to 30 degrees 67. The nurse has given activity guidelines to the client with chronic lower back pain. The nurse determines that the client understood the instructions if the client states to avoid which of the following positions? a. Lying on the side with knees and hips bent b. Lying prone c. Standing with one foot on a step or stool d. Sitting using a lumbar roll or pillow 68. The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific physician orders, the nurse would avoid placing the client in which of the following positions? a. Neck in neutral position c. Flat with head turned to the side b. Head of bed elevated 30 to 45 degrees d. Head midline 69. The nurse has admitted a client to the clinical nursing unit following modified right radical mastectomy for the treatment of breast cancer. The nurse plans to place the right arm in which of the following positions? a. Elevated above shoulder level c. Level with the right atrium b. Elevated on a pillow d. Dependent to the right atrium 70. The parents of a child with a cleft lip are concerned and ask the nurse when the lip will be repaired. The nurse supportively tells the parents that. a. cleft lip repair usually is performed between 6 months and 2 years of age b. cleft lip repair usually is performed by 6 months of age c. cleft lip repair usually is performed during the first weeks of life d. cleft lip cannot be repaired

71. The client was hospitalized for a cervical radiation implant. The implant is removed, and the nurse provides home care instructions to the client. Which statement made by the client indicates a need for further instructions? a. cream may be used to relieve dryness or itching b. foul-smelling vaginal discharge is a sign of an infection c. sexual intercourse may be resumed after seven to ten days. d. some vaginal bleeding is expected for one to three months. 72. The nurse teaches skin care into the client receiving external radiation therapy. Which of the following statements. If made by the client would indicate the need for further instruction? a. I will handle the area gently b. I will avoid the use of deodorants c. I will limit sun exposure to one hour daily d. I will wear loose fitting clothing 73. The client with diabetes mellitus calls the clinic and tells the nurse that he has been nauseated during the night. The client asks the nurse if the morning insulin dose should be administered. Which of the following is the most appropriate nursing response? a. omit the insulin c. administer the full dose as prescribed b. administer half of the prescribed dose. d. wait until noon before making a decision 74. The nursery room nurse is assessing a newborn infant who was born to a mother who abuses alcohol. Which of the following assessment findings would the nurse expect to note? a. lethargy c. irritability b. higher than normal birth weight d. a greater than normal appetite when feeding 75. Oral iron supplements are prescribed for the 6year-old child with iron deficiency anemia. The nurse instructs the mother to administer the iron with which of the following food items? a. water b. milk c. apple juice d. tomato juice 76. A client arrives at the clinic complaining of fatigue, a lack of energy, constipation, and depression. Following diagnostic studies, hypothyroidism is diagnosed and levothyroxine (Synthroid) is prescribed. The nurse instructs the client that the expected outcome of the medication is to: a. increase energy levels b. achieve normal thyroid hormone levels c. increase blood glucose levels d. alleviate depression 77. A nurse is teaching a client who had a laryngectomy for laryngeal cancer how to use an artificial larynx. The nurse tells the client to: a. Insert the device into the tracheostomy b. Hold the device alongside the neck c. Hold the device over the upper portion of the sternum d. Swallow air into the esophagus to make speech 78. The school nurse is to monitor a child with suspected juvenile hypothyroidism. Which of the following would the nurse expect this child to manifest? a. short attention span and weight loss b. weight loss and flushed skin c. rapid pulse and heat intolerance

d. dry skin and constipation 79. The nurse observes a darkish blue pigment on the buttocks and back of an African american neonate. Which of the following actions would be most appropriate? a. ask the obsterstician to assess the child b. assess the child for other area of cyanosis c. document this observation in the child's record d. advise the mother that laser therapy will be needed 80. During a physical examination, the nurse observes a copper bracelet on a clients wrist. The client states that she is wearing it to treat her arthritis. Because the nurse is aware of different cultural beliefs, the nurse recognizes this as a health practice. a. in which a protective object is believed to ward off illness b. that is harmful to the client and must be discontinued c. that is quakery and should not be tolerated d. that is medically supported to treat arthritis and other conditions 81. The nurse advises a 42-year old client to have a screening mammogram. The client asks why this is necessary, since the performs breast self-examination (BSE) monthly. The nurse's best response is a. all women over 35 should have an annual mammogram. b. a mammogram can identify breast cancer before it is detectably by BSE. c. most women do not perform BSE thoroughly enough to detect cancer. d. a mammogram can detect other endocrine abnormalities as well. 82. Kurdapya is recovering from an infected abdominal wound. Which of the following foods should the nurse encourage the client to eat to support wound healing and recovery from the infection? a. Chicken and orange slices b. cheese burger and French fries c. cheese omelet and bacon d. gelatin salad and tea 83. BJ tells the nurse that he is afraid to undergo chemotherapy because of what he has heard about the side effects. What would be the nurses best response to the client's concerns? a. your health has been excellent. It is unlikely that you will experience serious side effects. b. we will give you medications to prevent the side effects, so you shouldnt be too concerned. c. each person's responds differently to the chemotherapy treatments. We will monitor your responses closely. d. It is important for you to accept this treatment. If you refuse chemotherapy therapy treatments, you will die. 84. A nurse is caring for a client who received an allogenic liver transplant. The client is receiving tactolimus (Prograf) daily. Which of the following indicates to the nurse that the client is experiencing an adverse reaction to the medication? a. A decrease in urine output b. Hypotension c. Profuse sweating d. Photophobia 85. A nurse is caring for a client with Bucks traction. Which assessment finding indicates a complication associated with this type of traction?

a. b. c. d.

Weak pedal pulses Drainage at the pin sites Warm toes with brisk capillary refill Complaints of discomfort

86. A nurse is performing an admission assessment on a client admitted with newly diagnosed Hodgkins disease. Which of the following would the nurse expect the client to report? a. Night sweats b. Severe lymph node pain c. Weight gain of 2kg d. Headache with minor visual changes 87. A nurse is assessing the casted extremity of a client. The nurse would assess for which of the following signs and symptoms indicative of infection? a. Coolness and pallor of the extremity b. Presence of a hot spot on the cast c. Diminished distal pulse d. Dependent edema 88. A nurse is caring for a client diagnosed with a skin infection. The client is receiving tobramycin sulfate (Nebcin) intravenously every 8 hours. Which of the following would indicate to the nurse that the client is experiencing an adverse reaction related to the medication? a. A blood urea nitrogen (BUN) of 30mg/dL b. A white blood cell count of 6000/l c. A sedimentation rate of 15mm/hr d. A total bilirubin of 0.5mg/dL 89. When a newborn is 12-hours-old, the nurse is to give him his first bath. The nurse should initially obtain which of the following assessments? a. Temperature c. size of posterior fontanel b. b. weight loss since birth d. passage of me conium 90. When caring for an adolescent who is diagnosed with idiopathic scoliosis, a nurse should recognize that the priority concern for the adolescent is related to a. Body image c. financial burden b. Activity limitations d. imposed dependence 91. A patient who has a pituitary adenoma is scheduled for a transsphenoidal hypophysectomy.A nurse is teaching the patient about what to expect in the immediate postoperative period. Which of these statements by the nurse would be accurate? a. You will have a pressure dressing on your head. b. You will have lie flat in bed. c. You will be unable to suck through a straw. d. You will be unable to brush your teeth. 92. Which of the following teaching instructions would a nurse include for a patient who has regional enteritis? a. Limit your dietary protein intake. C. Decrease your activity level. b. Reduce stress in your lifestyles. D. Avoid drinking fruit juices.

93. Which of the following statements, if made by a patient who has diverticulitis, would indicate to a nurse that the patient is following the diet plan correctly? a. I eat meat five times a week. C. I drink decaffeinated coffee. b. I do not eat dried foods. D. I eat a green salad every day. 94. Which of the following actions should the nurse take first following a violent episode on a psychiatric unit? a. Conduct a staff debriefing c. discuss the incident with other patients b. Contact hospital administration d. call hospital security 95. When taking a history from the parent of an eight-year-old child who has rheumatic fever, a nurse would expect the childs parent to report a recent episode of a. Urinary tract infection c. contact dermatitis b. Acute gastroenteritis d. acute pharyngitis

96. A patient with myasthenia gravis who is receiving pyridostigmine bromide (Mestinon) makes all of the following statements. Which one should indicate to a nurse that the Mestinon is having a therapeutic effect? a. My urine has no odor. C. My vision is less blurry. b. My headaches are gone. D. My chewing is stronger. 97. A child who has sickle cell anemia has been admitted to the hospital, Which of the following signs and symptoms must be reported to the physician immediately? a. Decreased urine output c. chest pain b. Vomiting and diarrhea d. nonproductive cough 98. Which of the following measures would a nurse include in the care plan of a patient who has a cerebellar tumor? a. Keep the room darkened c. provide memory aids b. Speak slowly and clearly d. ambulate with assistance

99. The nurse is caring for a patient with a diagnosis of pancreatitis. All of the following medications are ordered for the patient. Which one should the nurse question? a. Meperidine hydrochloride c. Propantheline bromide (Pro-Banthine) b. Morphine sulfate d. Cimetidine (Tagamet)

100. A parent calls the emergency department and tells a nurse, My two-year-old child ate about half a bottle of chewable vitamins, but seems to be feeling fine. Which of the following questions would the nurse ask the parent first? a. Were the vitamins in a locked cabinet? b. Have you notified your family doctor yet? c. Did you make your child vomit? d. Are the vitamins fortified with iron?