1.

2.

3.

A client as an obsessive-compulsive disorder

manifested by the compulsion of handwashing. The
nurse knows that which of the following best
describes the clients need for the repetitive acts of
handwashing?
a. Handwashing represents an attempt to
manipulate the environment to make it
more comfortable.
b. Handwashing externalizes the anxiety from
a source within the bidy to an acceptable
substitute outside the body.
c. Handwashing assists the client to avoid
undesirable thoughts and maintain some
control over guilt and anxiety.
d. Handwashing helps to maintain the client in
an active state to resist the effects of
depression.
Following the vaginal delivery of an 11-pound baby,
the nurse encourages the mother to breastfeed her
newborn. What is the primary purpose of this action?
a. To initiate the secretion of colostrum
b. To prevent neonatal hyperglycemia
c. To facilitate maternal-newborn interaction.
d. To stimulate the uterus to contract.
Client is admitted for a series of tests to verify the
diagnosis of Cushings syndrome. Which of the
following assessment findings, if observed by the
nurse, would support this diagnosis?
a. Buffalo hump, hyperglycemia, and
hypernatremia
b. Nervousness, tachycardia, and intolerance
to heat
c. Lethargy, weight gain and intolerance to
cold
d. Irritability, moon face and dry skin

4.

The nurse is caring for a child with acute renal

failure who is in the intensive care unit. Which
assessment finding would indicate a sign of
tonsialemia?
a. Seizure
b. ECG changes
c. Dyspnea
d. Oliguria

5.

In planning care for a 7-year-old client with Graves

disease, what should the nurse do?
a. Encourage frequent rest periods
b. Encourage strenuous physical activity
c. Administer thyroid hormone replacement
daily
d. Encourage a decrease caloric intake

6.

The nurse recognizes which of the following as early

sign of lithium toxicity?
a. Restlessness, shuffling gait, involuntary
muscle movements
b. Ataxia, confusion, seizures
c. Fine tremors, nausea, vomiting, diarrhea
d. Elevated white blood cell count, orthostatic
hypotension

7.

The nurse is preparing to do a shift assessment on a

client who was admitted with an upper
gastrointestinal bleed. Which signs and symptoms
would indicate active bleeding? (Select all that
apply)
a. Blood pressure 80/52 mmHg
b. Stool black and tarry
c. Hemoglobin 18g/dL
d. Hematocrit 32%
e. Heart rate 128 beats/min
f. Respirations 32 and shallow
Mr. Rollins is a known alcoholic who is brought to the
Emergency Department by the police. He has severe
ascites from his chronic alcoholism and the physician
prescribes spironolactone 50mg orally now. The
pharmacy dispenses spironolactone 25mg tablets.
How many tablets do you give Mr. Rollins?
a. 2 tablets

8.

b.
c.
d.
9.

0.5 tablet
4 tablets
1 tablet

A client is admitted with suspected pneumonia. The

chest xray reveals right middle and lower lunch
consolidation. During auscultation of the middle and
lower lobes, which finding related to the pulmonary
system would the nurse anticipate?
a. Inspiratory and expiratory wheezing
b. Decreased breath sounds
c. Tympanic hyperresonance
d. Bronchovesicular sounds

10. Prior to electroconvulsive therapy (ECT) treatment,

the patient receives an injection of a medication
that reduces secretions and protects against vagal
bradycardia. Which medication will you administer?
a. Fluoxetine (Prozac)
b. Diphenhydramine (Bendaryl)
c. Atropine
d. Epinephrine (Adrenalin)
11. Patient with Alzheimers wandering in the hallway,
which of the following should the nurse do?
a. Place in soft restraints
b. Place in a restraint chair in the nurse
station
c. Place chemical restraints
d. Ask relative to stay with the patient
12. Mrs. Robinson is a 38 year old woman being treated
on an outpatient basis for depression. Three months
ago, her husband revealed that he was having an
affair with her best friend and planned to file for
divorce. Three weeks ago, Mrs. Robinsons 14 year
old son (her only child) committed suicide on an
inpatient psychiatric mental health unit.in todays
therapy session, Mrs. Robinson reveals to her nurse
therapist that she is seriously contemplating suicide
herself. What action should the therapist take?
a. Arrange for voluntary hospitalization, if the
patient is willing
b. None, because people who speak of
committing suicide seldom do it
c. Arrange for immediate hospitalization
d. Request permission to speak with the
husband to suggest marriage counseling
13. A young adult client is scheduled for her first
debridement of a second-degree burn of the left
arm. It is most important for the nurse to take which
of the following actions?
a. Assemble all necessary supplies and
medications
b. Plan adequate time for the dressing change
and provide emotional support
c. Prepare the client and family for the pain
the client will experience during and after
the procedure
d. Limit visitation prior to the procedure to
reduce stress
14. The nurse is caring for a 67 years old man following a
cardiac catheterization. Two hours after the
procedure, the nurse checks the patients insertion
site in the antecubital space, and the patient
complains that his hand is numb. The nurse should:
a. Change the position of his hand
b. Check his grip strength in both hands
c. Notify the physician
d. Instruct the patient to exercise his fingers
15. A client is to receive 1000mL of IV fluid over 10
hours. The IV tubing set calibration is 15gtt/mL.how
many drops per minute would the nurse give?
a. 125gtt/min
b. 115gtt/min
c. 25gtt/min
d. 100gtt/min

16. Which intervention would the nurse anticipate for a

patient who is diagnosed with osteitisdeformans
(Pagets disease)?
a. Biphosphate and recommended doses if
calcium and vitamin D
b. Calcitonin and vitamin A supplements
c. Estrogen and physical therapy
d. A low-phosphorus and aerobic exercise

23. A 47 year old woman comes to the outpatient

psychiatric clinic for treatment of a fear of heights.
The nurse knows that phobias include:
a. Projection and displacement
b. Sublimation and internalization
c. Rationalization and intellectualization
d. Reaction formation and symbolization

17. The nurse has just received report from the previous
shift. Which of the following clients should the nurse
see first?
a. A client who is receiving a blood transfusion
and complains of a dry mouth
b. A client who is scheduled to receive heparin
and PTT is 70 seconds
c. A client who is receiving ciprofloxacin
(Cipro) and complains of fine macular rash
d. A client who is receiving IV potassium and
complains of burning at the IV site

24. When teaching a client with myasthenia gravis about

the management of the disease, what advice should
the nurse give to the patient?
a. Prevent structured, active exercises at least
twice a week to prevent muscle atrophy
b. Protect extremities from injury due to
decreased sensory perception
c. Arrange a routine to accommodate frequent
visits to doctors office
d. Perform necessary physically demanding
activities in the morning

18. Refer to the following list of drug indications,

actions and side effects. Which statement matches
with simvastatin (Zocor)?
a. Lowers LDL level, increase HDL level, and
slows progression of coronary artery
disease. Adverse effects may include
myopathy, and hepatotoxicity
b. Lowers LDL, triglycerides, and
apolipoprotein B levels by blocking
absorption in the gastrointestinal tract.
Minimal adverse effects have been
identified.
c. Lowers LDL cholesterol and VDL triglyceride
levels; raises HDL. May cause severe
flushing
d. Reduces VLDL and increases HDL levels.
Gastrointestinal disturbances and an
increased risk of gallstones may occur.

25. Client with paranoid thinks he is the son of the US

president. During interaction, he began to have
hallucinations again, which action should be done by
the nurse first?
a. Ignore the hallucinations and proceed with
the interaction
b. Recognize the patients anxiety the proceed
with the interaction
c. Let the hallucinations be the center or topic
of the interaction
d. Ask for help

19. A client is admitted with irritable bowel syndrome.

The nurse would anticipate the clients history to
reflect which of the following?
a. Pattern of alternating diarrhea and
constipation
b. Chronic diarrhea stools occurring 10-12
times per day
c. Diarrhea and vomiting with severe
abdominal distention
d. Bloody stools with increased cramping after
eating
20. The nurse is preparing to do postoperative
assessment on a 5 year old child who has undergone
tonsillectomy. During the assessment, the nurse
should be alert for bleeding. Which signs and
symptoms would indicate active bleeding? (select all
that apply)
a. Drowsiness
b. Dark red vomitus
c. Mouth breathing
d. Frequent swallowing
e. Frequent clearing of throat
21. The nurseis preparing to administer carvedilol
(Coreg) to a patient. Which action should the nurse
take first?
a. Find the results of the patients last blood
pressure measurement
b. Check the patency of the patients IV line
c. Assess the patients current pulse and blood
pressure
d. Review the patients urine output as
recorded by nurses on the previous shift.
22. Who to see first?
a. Post colectomy with abdominal cramping
b. Patient with post bone marrow transplant
with diarrhea
c. Patient with cast 30 minutes ago with
muscle spasm
d. Patient chemo with n/v

26. Your patient has been admitted in preterm labor and

is receiving magnesium sulfate as a tocolytic. You
prepare her for the common side effects of this
medication, which include drowsiness, lethargy,
feeling warm and
a. Palpitations
b. Muscular weakness
c. Tremulousness
d. Tachycardia
27. A client has just been admitted after sustaining a
second-degree thermal injury to his right arm. Which
of the following nursing observations is most
important to report to the doctor?
a. Pain around the periphery of the injury
b. Gastric pH less than 6.0
c. Increased edema of the right arm
d. An elevated hematocrit
28. Which drug would the nurse question?
a. Prozac for client with bulimia
b. Seroquel for patient with undifferentiated
schizophrenia
c. Olanzapine for OC
d. Buspar for client with anxiety
29. A patient with Raynauds disease should be taught to
avoid which environmental factor?
a. High levels of smog
b. Cold temperature
c. Exposure to secondhand smoke
d. Contact with pesticide
30. Which statement by a 7-year-old client would
indicate an understanding of when to take
medication (via inhaler)?
a. After one puff, I can immediately give
myself another puff
b. I need to depress the top of the inhaler as
I begin to take a breath.
c. When I remove the inhaler, I can exhale
through my mouth.
d. I need to inhale the medicine and then
hold my breath to the count of 10.
31. To detect diabetic ketoacidosis (DKA), which of
following would you test for ketones?
a. Plasma

b.
c.
d.

Feces
Urine
Sputum

32. A client has been diagnosed with metastatic cancer

with a poor prognosis. Recently, the client has
complained of increased pain and is less
communicative, very irritable, and anorexic. Which
of the following nursing goals should be a priority at
this time?
a. Encourage client to talk about the
possibility of dying.
b. Provide pain assessment and effective pain
management
c. Manage nutrition and hydration
d. Verify that the physician has discussed the
prognosis with the family
33. A 60-year old man with a diagnosis of pneumonia is
being admitted to the medical/surgical unit. The
nurse should place the patient in a room with which
of the following patients?
a. A 20-year-old in traction for multiple
fractures of the left lower leg
b. A 35-year-old with recurrent fever of
unknown origin
c. A 50-year-old recovering alcoholic with
cellulitis of the right foot
d. An 89-year-old with Alzheimers disease
awaiting nursing home placement
34. A patient is hospitalized for severe pregnancyinduced hypertension (PIH). Her hematocrit has
increased two points since the previous day. What is
the probable cause of this increase?
a. A shift of red blood cells from the fetus
b. A shift of fluid from the vascular
compartment
c. Decreased red blood cell destruction by the
spleen
d. Increased hematopoiesis in the red bone
marrow
35. Lucy is a 34-year-old married woman with chronic
low self-esteem. Which action by Lucy demonstrates
assertive behavior and positive interpersonal
relationships?
a. Lucy requests that her husband join her
weekly sessions to deal with the husbands
use of alcohol and extramarital affair.
b. Lucy cries for 28 minutes of the 30-minute
therapy session
c. Lucy says to the nurse, My husbands
behavior gives me headaches, so I sleep a
lot.
d. Lucy says to the nurse, I am going to make
other peoples lives as miserable as mine
is.
36. The nurse on a psychiatric unit of the hospital
refuses to agree to a 32-year-old patients request to
organize a party on the unit with his friends. The
patient becomes angry and uses abusive language
with the nurse. Which of the following statements
indicates that the nurse has an understanding of the
patients behavior?
a. Allowing the patient to use abusive
language will undermine the authority of
the nurse.
b. Responding in kind to a patient who uses
abusive language will perpetuate the
behavior.
c. Abusive language is one the behaviors that
is a symptom of the patients illness.
d. The nurse should model acceptable
behavior and language for all patients.
37. You are caring for a 7-year-old client with a brain
tumor. Which observation would alert you to the

possible development of syndrome of inappropriate

antidiuretic hormone secretion (SIADH)?
a. Serum sodium of 130 mEq/L
b. Weight loss
c. Urinary output of 30mL/h
d. Peripheral edema
38. The nurse is preparing a client for a skin biopsy.
Which of the following client statements should the
nurse report to the physician?
a. Ive been taking aspirin for my sore
knees.
b. Using lotion has helped my dry skin.
c. I went to the tanning salon yesterday.
d. I had a big breakfast this morning.
39. Endoscopic Retrograde Choliangopancreatography
(ERCP) SATA
a. Check for gag reflex postprocedure
b. No discomfort post-procedure
c. Anesthesia will be used
d. No special prep needed
e. NPO prior to procedure
f. Will stay in hosp for a few days post op
40. The patient is taking ibandronate (Boniva) for the
prevention of osteoporosis. Which statement should
be part of the patient education provided by the
nurse?
a. Take the medication with a minimal
amount of fluid just before bedtime.
b. Take the drug first thing in the morning
with a full glass of milk or juice.
c. Take the medication on a full stomach
immediately after meal.
d. Take the medication in the morning with a
glass of water and then dont ingest
anything for 30 minutes.
41. The nurse has administered sublingual nitroglycerin
(Nitrostat) to a client complaining of chest pain.
Which of the following observations is most
important for the nurse to report to the next shift?
a. The client indicates the need to use the
bathroom.
b. Blood pressure has decreased from 140/80
to 90/60.
c. Respiratory rate has increased from 16 to
24.
d. The client indicates that the chest pain has
subsided.
42. In planning care for a client with cirrhosis who was
admitted with bleeding esophagealvarices, to which
goal should the nurse assign the highest priority?
a. Maintain fluid volume
b. Relieve clients anxiety
c. Maintain airway patency
d. Control the bleeding
43. A client is admitted to the neurology unit for a
myelogram. It would be most important for the nurse
to ask which of the following questions?
a. Do you have any allergies?
b. Have you been drinking lots of fluids?
c. Are you wearing any metal objects?
d. Are you taking medication?
44. A nursing assistant is assigned to constant
observation of a suicidal patient, and the nurse
overhears the nursing assistant talking with the
patient. Which of the following statements made by
the nursing assistant would require immediate
intervention by the nurse?
a. Lets put your clothes in the dresser.
b. Ill stay in the bathroom with you while
you take your shower.
c. Youre going to be moved to private room
later today.

d.

Ill be right back with something for you to

eat.
45. A patient diagnosed with angina is instructed to rest
when having an episode of chest pain. What is the
best explanation for how rest relieves the pain
associated with angina?
a. Increased venous return to the heart
decrease myocardial oxygen needs.
b. Coronary arteries constrict and shunt blood
to vital areas of the myocardium.
c. A balance between myocardial cellular
needs and demand is achieved.
d. Coronary blood vessels dilate and increase
myocardial cell perfusion.
46. Twelve hours after a total thyroidectomy, the client
develops stridor on exhalation. What is the nurses
best first action?
a. Hyperextend the client's neck.
b. Reassure the client that the voice change is
temporary.
c. Call for emergency assistance.
d. Document the finding as the only action.
47. Which of the following is the first nursing action that
should be implemented for a 25-year-old woman
after a vaginal delivery?
a. Check the patients lochial flow
b. Palpate the patients fundus
c. Monitor the patients pain
d. Assess the patients level of consciousness
48. The nurse is caring for a client receiving
amphotericin B (Fungizone) 1mg in 250cc of 5%
dextrose in water IV over a 2-hour period. The nurse
should be most concerned if which of the following
was observed?
a. BUN 7.2 mg/dL, creatinine 0.5 mg/dL.
b. BP 90/60, complaints of fever and chills.
c. Complaints of burning on urination, thirst,
and dizziness.
d. AST (SGOT) 12 U/L, ALT (SGPT) 14 U/L,
total bilirubin 0.2 mg/dL.
49. What equipment would be necessary for the nurse to
complete an evaluation of cranial nerve III during a
physical assessment?
a. Tongue depressor
b. A pen light
c. A cotton swab
d. A safety pin
50. A G1P0 30-year-old patient at 38 weeks gestation is
admitted with heavy, bright red bleeding. The initial
nursing assessment should include all of the
following except?
a. Fetal monitoring
b. Asking about the pain
c. Taking vital signs
d. A vaginal examination
51. A 12-year-old client has a right tibia fracture that is
casted. The client needs instruction regarding how
to walk in crutches using a three-point gait prior to
be discharged from the Emergency Department.
Which instructions would be included? (SATA)
a. The hands and arms support the bodys
weight
b. The body swings through and beyond the
crutches
c. The right foot acts like a balance
d. Advance both crutches and swing both feet
forward
e. Weight bearing is permitted on the right
foot
f. Weight bearing is permitted on the left foot
g. The axillary area supports the body weight
52. Which patient is robust?
a. Pulse pressure of 40
b. BP of 90/60
c. RR of 8

d.

CVP of 30cmH2O

53. What action should the nurse take when performing

intermittent nasogastric (NG) feedings in a client?
SATA
a. Keep the head of the bed elevated at 15
degrees
b. Irrigate the NG tube prior to initiating
feeding
c. Deliver feedings through a syringe barrel
attached to the NG tube
d. Deliver the feeding by pushing on the
syringe plunger
e. Aspirate the stomach contents
f. Clamp the NG tube once the feeding is
complete
54. A patient with chronic mental health problems has
been making progress with treatment. During the
most recent visit to the clinic, however, the patient
tells the nurse he lost his job and feels useless
because he is unable to provide for the family. Which
nursing diagnosis would be most appropriate for this
patient?
a. Social isolation
b. Caregiver role restrain
c. Situational low self-esteem
d. Anxiety
55. To minimize the side effects of a DPT immunization
for a six-month-old, the nurse should instruct the
parents to:
a. Give the child an alcohol bath for an
elevated temperature
b. Administer antipyretics for discomfort,
irritability, and fever
c. Place an ice bag on the childs leg for three
days
d. Check the childs temperature every four
hours for three days
56. On admission, the vital signs of a client with a closed
head injury were temperature of 98.6F, blood
pressure 128/68mmHg, heart rate 110beats/min,
respiration 26. One hour after admission, the nurse
observes that the client may be experiencing
Cushings triad. Which vital signs are indicative of
Cushings triad?
a. Blood pressure 110/70mmHg, heart rate
120beats/min, respiration 30
b. Blood pressure 130/72mmHg, heart rate
90beats/min, respiration 24
c. Blood pressure 152/88mmHg, heart rate
122beats/min, respiration 16
d. Blood pressure 150/70mmHg, heart rate
80beats/min, respiration 14
57. A female client is diagnosed with human
papillomavirus (HPV). Which of the following client
statements, if made to the nurse, illustrates an
understanding of the possible sequelae of this
illness?
a. I will need to take antibiotics for at least a
week.
b. I will use only prescribed douches to avoid
a recurrence.
c. I will return for a Pap smear in six
months.
d. I will avoid using tampons for eight weeks.
58. The nurse is caring for a client with a cervical spinal
cord injury. Vital signs and laboratory results for this
client are as follows:
Blood pressure: 128/72 mmHg
Heart rate: 94 beats/min
Arterial pH: 7.3
Arterial pCO2: 60 mmHg
Arterial pO2:75 mmHg
Arterial HCO3: 35 mEq/L
Based of this information which nursing action would
be the best action?

a.
b.
c.

d.

Notify the physician, request an order for

midazolam, and reevaluate the client in 30
minutes
Evaluate airway patency, place the client in
high Fowlers position, and encourage
coughing and deep breathing
Notify the physician, inform the physician
about the clients metabolic acidosis and
anticipate a sodium bicarbonate continuous
infusion
Evaluate airway patency, administer pain
medication and encourage coughing and
deep breathing

59. A patient diagnosed with gout asks, Is there

anything I can do to decrease my uric acid levels?
What is the nurses most appropriate response?
a. Avoid strenuous activity, as it will cause
muscle breakdown.
b. Decrease the amount of liver, sardines, and
shrimp in your diet
c. Increase the amount of citrus fruits in your
diet
d. Drink at least 1 to 1.5 liters of fluid each
day.
60. During the nursing history interview, a preschool
clients mother reports that the child has frequent
bouts of gastroenteritis. It would be most important
for the nurse to ask which of the following questions?
a. Are there other children in the family?
b. Does the child attend a day care center?
c. Does the child play with neighborhood
children?
d. Is the child current on his immunizations?
61. A 9-year-old client is given his heparin injection on
time, but it was administered intravenously instead
of subcutaneously. The incident was discovered 2
hours after administration. Which plan would be
most appropriate?
a. Document the event on an incident report
and notify the physician
b. Hold the next scheduled heparin dose
c. Order a PTT and INR levels and notify the
physican
d. Assess for evidence of bleeding and notify
the parents
62. A client is diagnosed with lung cancer and undergoes
a pneumonectomy. In the immediate postoperative
period, which of the following nursing assessment is
most important?
a. Presence of breath sounds bilaterally.
b. Position of the trachea in the sternal notch.
c. Amount and consistency of sputum.
d. Increase in the pulse pressure.
63. The nurse receives a phone call from a nursing
assistant who states that her five-year-old child has
developed chickenpox. It would be most important
for the nurse to ask which of the following questions?
a. Have your other children had chickenpox?
b. Does your child have a temperature?
c. Have you had the chickenpox?
d. Do you have someone to watch your
child?
64. Mr. Holloway has just received his first dose of this
antipsychotic medication perphenazine (Trilafon) you
know that the response time to the medication for
cognitive and perceptive symptoms, such as
hallucinations, delusions and thought broadcasting,
may take how long?
a. From 28-52 weeks
b. Up to 3 minutes
c. Up to 30 minutes
d. From 2 to 8 weeks
65. A patient who is 28 weeks pregnant complains of
lower back pain. What should the nurse suggest?
a. The patient take Motrin as needed

b.
c.
d.

Lower back pain is part of being pregnant

and there is nothing the patient can do
about the pain
The patient pay close attention to her body
posture and mechanics, as these are the
cause of back pain in pregnancy
The patient tell her provider immediately,
because she is in preterm labor

66. The nurse has collected the following data: client

anger directed toward staff in the form of frequent
sarcastic or crude comments, increased wringing of
hands, and purposeless pacing, particularly after the
client has used the telephone. Based on this data,
the nurse should make which nursing diagnosis?
a. Impaired social interaction related to
conversion reaction
b. Risk for potential activity intolerance as
evidenced by purposeless pacing
c. Powerlessness in hospital situation
d. Ineffective individual coping related to
recent anger and anxiety
67. An adult patients prescription reads as follows,
Infuse 80 mEq of potassium chloride in 100 cc D5W
over 30 minutes. Based on the nurses understanding
of potassium administration, what is the most
appropriate action?
a. Contact the prescriber about the order
b. Monitor the EKG during the medications
administration
c. Switch the administration route to oral
d. Administer the medication
68. The nurses aide comes to take a woman by
wheelchair for a magnetic resonance imaging (MRI)
scan of the head and neck. Which of the following
observations, if made by the nurse, would require an
intervention?
a. The woman removes her dentures and gives
them to her husband.
b. The womans vital signs are: BP 120/70,
pulse 80, respirations 12, temperature 99F
(37.3C).
c. The woman has a nitroglycerine patch on
her right chest area.
d. The woman has red nail polish on her
fingers and toes.
69. A middle-aged man is admitted to an inpatient
psychiatric unit. Over the last several months he has
become convinced that his brother is trying to steal
his property. He is diagnosed with paranoid disorder.
The nurse knows that this client is demonstrating
which of the following
a. Delusions of persecution
b. Command hallucination
c. Delusions of reference
d. Persecution hallucination
70. A client returns to the unit from the recovery room
following a laryngoscopy. Which position would be
most effective in helping the client breathe?
a. Side-lying position
b. Sims position
c. Low fowlers position
d. Trendelenburg position
71. For the following herbal supplement, select the
purported use of: Black cohosh (Cimcifugaracemosa)
a. Used to relieve symptoms associated with
benign prostatic hypertrophy
b. Used to relieve symptoms of menopause
c. Used to relieve depression
d. Used to improve memory, sharpen
concentration and promote clear thinking
72. What is the highest priority in providing care to a
client who is admitted to the hospital with sickle cell
crisis?
a. Insist the client rest instead of visiting with
family
b. Administer prophylactic antibiotics

c.
d.

Initiate intravenous fluids to maximize

hydration
Insert urinary catheter to measure accurate
output

73. To maintain normalized blood sugars, Mr. Hernandez

has the following sliding scale insulin prescription:
Blood glucose < 130mg/dl: administer 0 unit of
insulin
Blood glucose 130-160mg/dl: administer 2 unit of
insulin
Blood glucose 161-190mg/dl: administer 4 unit of
insulin
Blood glucose 191-220mg/dl: administer 6 unit of
insulin
Blood glucose 221-250mg/dl: administer 8 unit of
insulin
Blood glucose >250mg/dl: administer 10 unit of
insulin and contact the physician immediately
Mr. Hernandez blood sugar is 122. What is your
intervention?
a. administer 2 unit of insulin
b. administer 4 unit of insulin
c. administer no of insulin and contact the
physician immediately
d. administer no insulin
74. A patient with Alzheimers disease doesnt want to
take a bath, what will the nurse do?
a. Call two staff nurses to help you bathe the
patient
b. Attempt to bathe the patient slowly and
calmly
c. Ask the patient the reason why she doesnt
want to take a bath
d. Document refuse to take a bath
75. Mr. Allen has psychosis and has been treated with
haloperidol (Haldol). You need to assess him for
movement disorders as a side effect of Haldol. What
is another name for these movement disorders?
a. Delusion etiologies
b. Extrapyramidal reactions
c. Autonomic dysreflexia
d. Biologic rigidity reactions
76. Identify the location on the chest area where the
nurse would take an apical pulse.
a. Right 5th intercostal space, midclavicular
line
b. Left 8th intercostal space
c. Right 8th intercostal space
d. Left 3rd intercostal space, midclavicular line
77. A client with deep vein thrombophlebitis suddenly
develops dyspnea, tachypnea, and chest pain. What
is the nurses initial, most appropriate action?
a. Apply 100% oxygen via face mask
b. Obtain a 12-lead ECG
c. Assess the clients blood pressure and heart
rate
d. Auscultate for abnormal heart sounds
78. The nurse is planning discharge for a group of
clients. It is most important to refer which of the
following clients for home care?
a. A postoperative appendectomy client who is
complaining of incisional pain
b. A diabetic client who had a cardiac
catheterization in the early AM
c. A postoperative cholecystectomy client who
is complaining of incisional pain
d. A client with congestive heart failure who
underwent diuresis in the hospital
79. Which instruction would be given to a client who is
receiving oral methylprednisolone regarding when
and how to take the medication?
a. Once a day before bedtime
b. Consume 10-12 glasses of water per day
c. Once a day on an empty stomach
d. Once a day with breakfast

80. A patient with osteoarthritis has had hip

replacement surgery. What level of activity would
the nurse anticipate for the first postoperative day?
a. Paresthesia, rigidity, aphasia
b. Tremors, rigidity, bradykinesia
c. Spasticity, diplopia, paresthesia
d. Dysarthria, dysphagia, ataxia
81. A patient with acute coronary syndrome is
administered thrombolytic therapy. Which portion of
the EKG tracing would the nurse observe to
determine the effectiveness of the medication?
a. ST segment elevation
b. PR interval
c. QT interval
d. Width of QRS complex
82. The nursing assistant reports to the nurse that a
client who is one-day postoperative after an
angioplasty is refusing to eat and states, I just
dont feel good. Which of the following actions, if
taken by the nurse is best?
a. The nurse talks with the client about how
he is feeling
b. The nurse instructs the nursing assistant to
sit with the client while he eats
c. The nurse contacts the physician to obtain
an order for an antacid
d. The nurse evaluates the most recent vital
signs recorded in the chart
83. An 18 month old client is admitted to the hospital
with a fever of 104F, respirations of 56/min,
suprasternal retractions and a pulse oximeter
reading of 85%; the infant is also drooling. Acute
epiglottitis is suspected. Which equipment would be
important to have at the bedside?
a. Tracheostomy tray
b. Intravenous infusion pump
c. Defibrillator
d. Code cart
84. Match the eating disorder with the correct
description of the disease. An excessive concern over
gaining weight and a refusal to maintain a minimally
normal body weight.
a. Bulimia nervosa
b. Anorexia nervosa
85. Among the four patients, who warrants immediate
attention?
a. Patient taking Glucophage with glucose
reading of 185mg/dl
b. Patient who had a spinal injury and is
complaining of throbbing headache
c. Patient diagnosed with seizure who wants to
change medication time
d. Patient with osteoarthritis experiencing
joint stiffness
86. Which drug would the nurse anticipate administering
for the treatment of inflammation of acute
exacerbations of gout?
a. Allopurinol (Zyloprim)
b. Acetaminophen (Tylenol)
c. Probenecid (Benemid)
d. Colchicine (novocholchicine)
87. A client returns to the unit undergoing a right
modified radical mastectomy with dissection of the
axillary lymph nodes. Which measure is an
appropriate intervention for the nurse to include in
the clients postoperative care?
a. Encourage the client to obtain a permanent
breast prosthesis upon discharge from the
hospital
b. Instruct the client to watch the clock and
use the PCA pump every 10 minutes
c. Insist that the client examine the surgical
incision when the surgical dressings are
removed

d.

Post a sign at the bedside to avoid pressure

measurements or venipunctures in the right
arm.

88. Patient with HIV states, I am so tired, my life is

useless, I am going to die anyway.
a. Refer to support group
b. Why are you tired?
c. What is the specific cause that makes you
feel tired?
d. Do you think you are dying?
89. After receiving a total hip replacement, the client
returns to the unit with an abductor pillow in place.
The client informs the nurse that he would be more
comfortable without the pillow. What is the nurses
best response?
a. The pillow is intended to prevent the
inadvertent movement of the left leg
beyond the bodys midline.
b. The pillow is intended to prevent early
ambulation if you should wake up
confused.
c. The pillow is intended to prevent the
inadvertent movement of the left leg too
far way from the body.
d. The pillow is intended to prevent the
contact of both knees and reduce the risk
that pressure ulcers will form.
90. The triage nurse for a womens health center
receives a phone call from each of the following
women. Which woman should be directed to come to
the health care facility immediately?
a. A multipara woman who is four weeks
pregnant and reporting unilateral, dull,
abdominal pain.
b. A primipara woman who is seven weeks
pregnant and reporting increase in whitish
vaginal secretions.
c. A primigravida woman who is five weeks
gestation and is having vaginal spotting and
some cramping.
d. A multigravida woman who is six weeks
pregnant and reporting frank, red vaginal
bleeding with moderate cramps.
91. Erythromycin ophthalmic ointment 0.5% is given
immediately after an infant is born to provide
prophylaxis against:
a. Chlamydia trachomatis
b. Syphilis
c. Both Neisseria gonorrhoea and chlamydia
trachomatis
d. Neisseria gonorrhoea
92. Which food choice would be most appropriate for a
patient with osteoporosis who wants to increase
calcium intake?
a. 1 ounce of cream cheese
b. 1 medium stalked of cooked broccoli
c. 3 ounces of beef
d. 1 medium apple
93. Which EKG tracing would the nurse recognize as an
early indicator of hyperkalemia?
a. Depressed ST segment
b. Prolonged QT interval
c. Shallow, flat, inverted T wave
d. Tall peaked T-wave
94. A 4-year-old has been admitted with second-degree
burns and is undergoing debridement of the wounds.
Morphine 1 mg IV push has been administered.
Following administration of this medication, the
nurse makes the following observations:
Pulse: 96
Respirations: 28
Blood pressure: 84/62
Child sleeping quietly
Which nursing action is most appropriate?
a. Keep the code cart at the bedside

b.
c.
d.

Allow the child to sleep quietly

Administer nalozone (Narcan)
Administer 100% oxygen

95. Individuals with diabetes mellitus can have a chronic

complication in which there is pain in the lower
extremities due to lack of blood supply. What is the
complication called?
a. Retinopathy
b. Claudication
c. Stroke
d. Angina
96. The nurse is assessing an infant who had a repair of a
cleft lip and palate. The respiratory assessment
reveals that the infant has upper airway congestion
and slightly labored respirations. Which of the
following nursing actions would be most appropriate?
a. Elevate head of the bed
b. Suction the infants mouth and nose
c. Position the infant on one side
d. Administer oxygen until breathing is easier
97. Why is maintaining a thermoneutral environment
essential for the neonate?
a. A thermoneutral environment permits the
neonate to maintain a normal core
temperature with increased caloric
consumption
b. Metabolism slows dramatically in the
neonate who experiences cold stress
c. The neonate produces heat by increasing
activity and shivering
d. A thermoneutral environment permits the
neonate to maintain a normal core
temperature with minimum oxygen
consumption
98. A six-month-old infant has had all the required
immunizations. The nurse knows this would include
which of the following?
a. Two doses of diphtheria, tetanus, and
pertussis vaccine
b. Measles, mumps and rubella vaccines
c. A booster dose of trivalent oral polio
vaccine
d. Chickenpox and smallpox vaccines
99. A 4-year-old child presents with possible rheumatic
fever. Which findings will the nurse observe in this
patient?
a. Decreased antistreptolysin-O titer
b. Decreased erythrocyte sedimentation rate
c. Macular rash that is pruritic
d. Elevated C-reactive protein levels
100.The nursing evaluation of the respiratory status of a
3-year-old client who is newly admitted with acute
epiglottitis would indicate the following findings:
a. Drooling, decreased pulse and stridor
b. Irritability, drooling and absence of
spontaneous cough
c. Irritability, coarse crackles bilaterally and
low-grade fever
d. Croupy cough, high fever and hoarseness
101.A client with necrotizing spider bite is to perform his
own dressing changes at homes. The nurse is aware
that which of the following statements, if made by
the client, indicates understanding of aseptic
technique?
a. I need to buy sterile gloves to redress this
wound.
b. I should wash my hands before redressing
my wound.
c. I should keep the wound covered at all
times.
d. I should use an over-the-counter
antimicrobial ointment.
102.A 22-month-old child is hospitalized for heart failure.
During the night, the child awakens crying and

calling for the mother. The nurse assesse the child

and notes dyspnea, jugular vein distention, crackles
and pink, frothy sputum. After the nurse begins
oxygen by 40% face mask, which action should be
taken next?
a. Dim the lights and allow the mother to rock
the child to sleep
b. Continue to monitor the client frequently
and increase fluid rate
c. Place the child in a crib with a blanket and
notify the physician
d. Stay with the child and call for assistance to
notify the physician
103.An elderly patient has been prescribed aspirin for
osteoarthritis. What should the nurse teach the
patient to ensure safe use of this medication?
a. A prothrombin time should be drawn upon
initiation of therapy and every 2 months
b. The prescriber should be notified if the
patient experiences any unusual bruising or
bleeding
c. The medication should be taken on an
empty stomach
d. Enteric-coated tablets should be crushed to
make the medication easier to swallow
104.The nurse is caring for client in the outpatient clinic.
Which of the following messages should the nurse
return first?
a. A mother reports that the umbilical cord of
her five-day-old infant is dry and hard to
touch.
b. A mother reports that the soft spot on the
head of her four-day-old infant feels slightly
elevated when the baby sleeps.
c. A mother reports that the circumcision of
her 3-day-old infant is covered with
yellowish exudate.
d. A father reports that her bumped the crib of
his two-day-old infant and she violently
extended her extremities and returned to
their previous position.
105.Indomethacin is given as a treatment for preterm
labor. What is a potentially significant fetal side
effect of this drug?
a. Premature closure of the ductusvenosus
b. Bradycardia
c. Decreased fetal movement
d. Premature closure of the ductusarteriosus
106.The nurse is caring for a client with internal
radiation. Which of the following actions, if taken by
the nurse, is most important?
a. Restrict visitor who may have an upper
respiratory infection
b. Assign only male caregivers to the client
c. Plan nursing activities to decrease nurse
exposure
d. Wear a lead-lined apron whenever
delivering client care
107.The nurse is caring for a client who sustained severe
burns and has an inhalation thermal injury. The
client is intubated and on the ventilator at 60% FiO2.
The nurse notices that the client is restless,
thrashing, and attempting to cough, the respiratory
rate is 34. What should the nurses first action be?
a. Administer pain medication
b. Increase the FiO2 setting to 100%
c. Auscultate lung sounds and suction if
needed
d. Notify the physician and prepare for
immediate surgery
108.A 22-month-old client is receiving Nystatin 200,00
units via oral swab every 6 hours. For which side
effects should the nurse assess the client?
a. Leukopenia
b. Oral thrush
c. Diarrhea

d.

Thrombocytopenia

109.The nurse is performing discharge teaching on a

client with multiple sclerosis. It is most important
for the nurse to include which of the following
instructions?
a. Ambulate as tolerated every day
b. Avoid overexposure to heat or cold
c. Perform stretching and strengthening
exercises
d. Participate in social activities
110.A client is being prepared for surgical repair of an
abdominal aortic aneurysm. The nurse suspects
complete aortic dissection when:
a. The client becomes hypotensive and
unresponsive
b. A bruit and thrill are palpable at the
aneurysm site
c. The client becomes hypertensive and
tachycardic
d. The client complains of sever leg and arm
pain
111.The nurse is caring for patients on the surgical floor
and has just received report from the previous shift.
Which of the following patients should the nurse see
first?
a. A 35-year-old admitted 3 hours ago with a
gunshot wound, 1/5 cm area of dark
drainage noted on the dressing.
b. A 43-year-old who had mastectomy two days
ago, 23 cc of serosanguinous fluid noted in
the Jackson-Pratt drain
c. A 59-year-old with a collapsed lung due to
an accident, no drainage noted from the
chest tube in the last eight hours
d. A 62-year-old who had an abdominalperineal resection three days ago, patient
complains of chills
112.Which of the following statements, if made by the
parents of a nine-year-old client with an ostomy,
would indicate to the nurse that they are providing
quality home care?
a. We change the bag at least once a week
and we carefully inspect the stoma at that
time.
b. We change the bag every day so that we
can inspect the stoma and the skin.
c. We encourage our daughter to watch TV
while we change her ostomy bag.
d. We only change the ostomy bag every ten
days.
113.Nursing care in the first 30 minutes after a caesarean
section includes:
a. Fundal and lochial assessment
b. Ambulation
c. Vital signs every hour
d. Oral hydration and nutrition
114.Education about health promotion is often effective
during periods of role transitions. Which of the
following is a role transition?
a. Retirement
b. Buying a new car
c. Moving into a new house in the same
neighbourhood
d. Going grocery shopping
115.An extremely angry patient with bipolar illness tells
the nurse he just learned his wife filed for divorce,
and he needs to use the phone. Which of the
following responses by the most nurse is most
appropriate?
a. Allow the patient to use the phone
b. Confront the patient about his anger and
inappropriate plan of action
c. Do not allow the patient to use the phone
because he is an involuntary patient

d.

Set limits on the patients phone use

because he has been unable to control his
behaviour

116.A patients medicinal history includes the use of the

herbal medication garlic and the prescribed
medication warfarin (Coumadin). Based in the
nurses knowledge of drug-drug interactions, which
problem could occur when a patient takes both of
these products concurrently?
a. Elevated blood pressure
b. Decreased immune function
c. Altered renal perfusion
d. Increased bleeding potential
117.Which statement by a patient would indicate that
the patient is adapting well to changes in functional
status after experiencing a spinal cord injury?
a. I tire easily when I use my wheelchair just
around the house. I know I would get tired
if I tried to leave the house.
b. "My wife tries to get me to go to the grocery
store, but I don't like to go out much."
c. "I have all the equipment to take a shower,
but I prefer a bed bath, because it is
easier."
d. "I have been using the modified feeding
utensils at every meal. I still have spills, but
I'm getting better."
118.A client is receiving plasmapheresis treatments for
myasthenia gravis. Which observation would the
nurse identify as the desired response for this
treatment?
a. Increased ptosis
b. Decreased functional residual capacity
c. Ability to consume an entire meal
d. Need for frequent rest periods
119.A client is brought to the emergency room after a
motor vehicle accident that resulted in the client
sustaining a head injury. Which assessment should
the nurse perform immediately?
a. Assessment of the respiratory status
b. Assessment of pupils
c. Assessment of short-term memory
d. Assessment of motor function
120.To promote safety in the environment of a client
with a marked depression of T cells, the nurse
should:
a. Keep a linen hamper immediately outside
the room
b. Restrict eating utensils to spoons made of
plastic
c. Provide masks for anyone entering the room
d. Remove any standing water left in
containers or equipment
121.A nurse is caring for a client with a spinal cord
injury. Which observation would indicate this client
is exhibiting neurogenic shock?
a. Heart rate of 52 beats/min
b. Temperature of 102.5F
c. Heart rate of 115 beats/min
d. Cool, moist skin
122.The nurse is preparing a teaching plan for a patient
who is visually impaired. Which teaching strategy
should be included in the plan?
a. Provision of written information
b. Use of captioned video materials
c. Auditory or tactile materials
d. Use of a slow, deliberate speech pattern
123.A 19-year-old patient has just been admitted to the
detoxification unit after drinking a quart of vodka
every day for the past 3 weeks. What is the most
important nursing intervention on the day of
admission to reduce the risk of harm to this patient?
a. Give the patient a meeting schedule for
Alcoholic Anonymous

b.
c.
d.

Administer Librium as prescribed

Encourage the patient to attend group
therapy sessions
Explain the addictive process to the patient

124.The physician informs the nurse that a client needs

to be intubated. In preparing for the physician to
perform the intubation, which equipment is
appropriate for this procedure? (SATA)
a. Laryngoscope
b. Sterile gloves
c. Uncuffed endotracheal tube
d. Oral suction
e. Face mask
f. Ambu bag
125.A 23-year-old man comes to the AIDS clinic for
treatment of large, painful, purplish-brown open
areas on his right arm and back. The nurse should
instruct the client to:
a. Clean the area carefully with soap and
warm water every day and cover them with
sterile dressing
b. Soak in a warm tub twice a day and rub the
areas with a washcloth before covering
them
c. Shower daily using a mild antimicrobial soap
from a pump dispenser and leave the lesions
uncovered
d. Clean the lesion twice a day with a diluted
solution of povidone-iodine (Betadine) and
leave them open to the air
126.The nurse is admitting a client to the unit from the
postoperative recovery area after abdominal
exploratory surgery. After determining the clients
vital signs, which of the following activities should
the nurse perform next?
a. Position the client on her left side,
supported with pillows
b. Check the chart and determine the status of
the fluid balance from surgery
c. Check the clients abdominal dressing for
any evidence of bleeding
d. Monitor the incision and pulmonary status
for the presence of infection
127.A physician has written an order for an HIV-positive
infant to receive an oral polio immunization. Which
of the following nursing actions is most appropriate?
a. Wear gloves and gown when administering
the immunization
b. Administer the immunization as infant is
being discharged
c. Call the physician and discuss the rationale
for the immunization
d. Administer the medication in the same
manner as you would to any other infant
128.Mrs.Tungen, who has been diagnosed with bipolar
disorder, is receiving lithium and outpatient
therapy.She now complains of diarrhea, vomiting,
thirst, and coarsening hand tremors. What should the
nurse's first intervention be?
a. Hold the lithium, and call for an order to
obtain a lithium level.
b. Administer an antidiarrheal medication.
c. Obtain a stool sample for culture.
d. Begin an intravenous drip of D5 NS with
20 mg potassium chloride to infuse at 125
mL/h.
129.The nurse observes a client who is taking phenelzine
(Nardil) eating another clients lunch. After a few
minutes, the client complains of headache, nausea,
rapid heartbeat, and begins to vomit. The nurse
anticipates administering which of the following
medication?
a. Buspirone (Buspar)
b. Fluoxetine (Prozac)
c. Prochlorperazine (Compazine)
d. Nifedipine (Procardia)

130.An infant born with spina bifida and is scheduled for

surgery the next day. Which nursing action has the
greatest priority?
a. Preventing infection by supine positioning
b. Encouraging the parents to hold, cuddle and
feed the infant
c. Promoting range-if-motion exercises
d. Preventing rupture of the meningocele sac
131.The nurse is caring for a client admitted with acute
hypoparathyroidism. It is most important for the
nurse to have which of the following item available?
a. Tracheostomy set
b. Cardiac monitor
c. IV monitor
d. Heating pad
132.Which assessment finding indicates effective chest
compressions during CPR?
a. Pink mucous membranes
b. Palpable carotid pulse
c. Dilated pupils bilaterally
d. Sluggish capillary refill
133.A nasogastric tube is ordered to be placed in a
client. Organize the following steps in chronological
order as they relate to this procedure:
1. Lubricate the tube
2. Measure the tube for approximate placement
length
3. Place the client in a high Fowlers position
4. Advance the tube downward and backward
5. Insert the tube along the base of the nose
6. Check the position of the tube, and secure the
tube
a. 3,1,2,5,4,6
b. 2,3,1,5,4,6
c. 1,3,2,5,4,6
d. 3,2,1,5,4,6
134.A client has been receiving chlorpromazine
hydrochloride (Thorazine). When the nurse checks on
the patient, the patient is restless, unable to sit, and
complains of insomnia and fine tremors of the hands.
The nurse identifies which of the following as the
best explanation about why these symptoms are
occurring?
a. A side effect of the medication that will
disappear as time passes.
b. The reason the patient is receiving this
medication.
c. Extrapyramidal side effects resulting from
this medication.
d. An indication that the dosage of the
medication needs to be increased.
135.A client has a right-side pneumothorax and a chest
tube has been inserted. Which finding would indicate
that the chest drainage system is functioning
effectively?
a. Blood leaking around the chest tube
insertion site
b. Constant bubbling in the water seal
chamber
c. Absence of breath sounds on the right side
d. Bubbling in the suction chamber

a.
b.
c.
d.

Notify the physician

Order a thyroid-stimulating hormone level
Loosen the neck dressing
Offer mouth care

138.Select all self-care activities that persons should be

able to perform prior to discharge to home. (SATA)
1. Bathing
2. Banking
3. Dressing
4. Car oil change
5. Grooming
6. Hygiene
139.When to know if a 6 year old child has a
dysfunctional grieving after the death of a
grandparent?
a. The child refuses to eat and stays in his
room
b. The child re-enacts the funeral using his
stuff toys and pets
c. The child asks when he can play with
grandpa just after visiting his grave
d. The child states that his grandpa is just
sleeping and would wake up soon
140.Mr. Koo is prescribed chlorpromazine (Thorazine) as
an antipsychotic medication. When he comes to the
pill line in the hospital, he reports that he has taken
2 days worth of the medication as prescribed and is
now experiencing dizziness. What should your first
nursing intervention be?
a. Obtain a complete blood count and serum
ammonia level as prescribed
b. Assess blood pressure with the patient In
both the lying and standing positions
c. Assess the optic chiasm using an
ophthalmoscope
d. Obtain pulmonary function test, stat
141.A 9-year-old client is receiving one unit of packed
red blood cells. Which finding on assessment would
indicate a possible haemolytic reaction? (SATA)
a. Tightness in chest
b. Red or black urine
c. Shaking
d. Temperature of 97.6F
e. Flank pain
f. Bilateral crackles
142.The nurse is supervising the staff caring for clients
on the medical/surgical unit. The nurse observes the
student nurse enter wearing a gown, gloves, and a
mask. The nurse determines that the precautions are
correct if the student nurse is caring for which of the
following clients?
a. An infant diagnosed with respiratory
syncytial virus
b. A young child with a wound infected with S.
aureus
c. A teenager diagnosed with toxic shock
syndrome
d. A teenager diagnosed with rubella (German
measles)

136.Your patient, Mr. Lawrence, has been prescribed

Mucinex (guaifenesin) 300 mg orally daily as part of
his treatment for bronchitis. The pharmacy sends up
Mucinex 600-mg extended-release tablets. How
many tablets doo you give Mr. Lawrence?
a. 2 tablets
b. None
c. 0.5 tablet
d. 1 tablet. None.

143.A client is admitted in sickle cell crisis and is

receiving IV morphine by PCA pump. The nurse
makes the following observations:
Pulse: 73
Respirations: 6
Blood pressure: 112/72 mmHg
Client is quietly sleeping
Which nursing action is most appropriate?
a. Allow the client to sleep quietly
b. Administer 100% oxygen
c. Administer naloxone (Narcan) as prescribed
d. Keep the code cart at the bedside

137.On the second day after a subtotal thyroidectomy,

the client informs the nurse that she is experiencing
numbness and tingling around her mouth. What is
the nurses best first action?

144.An autoimmune disorder attacks the myelin sheaths

of nerve fibers in the central nervous system and
produces lesions called plaques. This statement
describes the pathophysiology of which disease?

a.
b.
c.
d.

Amyotrophic lateral sclerosis

Multiple sclerosis
Alzheimers disease
Myasthenia gravis

145.The multipdisciplinary team decides to implement

behaviour modification with a client. Which of the
following nursing actions is of primary importance
during this time?
a. Confirm that all staff members understand
and comply with the treatment plan.
b. Establish mutually agreed upon, realistic
goals.
c. Ensure that the potent reinforcers (rewards)
are important to the client.
d. Establish a fixed interval schedule for
reinforcement.
146.When completing discharge teaching for a patient
who has experienced a myocardial infarction, the
patient asks the nurse why aspirin has been
prescribed daily. What is the nurses best response?
a. The medication helps to maintain coronary
blood flow by decreasing platelet
aggregation in the coronary arteries.
b. Aspirin is used to prevent fever associated
with the inflammatory response in
myocardial infarction.
c. The medication increases the amount of
blood in the coronary arteries.
d. Aspirin is used as prophylactic analgesic to
reduce pain.
147.Which immunization should be withheld if patient
experiences seizures?
a. Hepatitis
b. DPT
c. OPV
d. Measles
148.A 2-month-old infant is 2 days postoperative
tracheoesophageal fistula repair. A complete blood
count reveals a haemoglobin of 8.6mg/dl and
erythrocyte count of 2.5 million/mm3. Which
symptoms would the nurse most likely find on
assessment?
a. Projectile vomiting after oral bottle feeding
b. Sluggish capillary refill and hypotension
c. Slight pallor and tires easily while crying
d. Tachycardia and flushing
149.The nurse is caring for a patient with acute coronary
syndrome who is receiving altaplase (tPA). Which
side effects should the nurse monitor the patient
for?
a. Hepatomegaly
b. Fluid retention
c. Bleeding
d. Muscle pain
150.Lamotrigine is given to clients to relieve them from
what?
a. Seizure
b. Joint stiffness
c. Blood pressure
d. Migraine
151.One of the goals the nurse and a client with
posttraumatic stress disorder (PTSD) mutually agreed
upon is that he will increase his participation in outof-the apartment activities. Which of the following
recommendations, if made by nurse, will be most
therapeutic to achieve this goal?
a. Take a day trip with a friend
b. Take an eleven-minute bus ride alone
c. Join a support group and participate in a
victim assistance organization
d. Take a ten-minute with his wife around the
block
152.The client is at risk for bleeding related to the
Vitamin K deficiency and the altered liver functions

a.
b.
c.
d.

Roasted chicken breast, baked potato with

margarine and chives and skim milk
Two eggs, two slices of toast with margarine
and a glass of whole milk
Baked fish, steamed broccoli with salt and
pepper, and a glass of iced tea
Grilled cheese sandwich, steamed
vegetables with butter and a cup of coffee

153.During a home visit, the nurse saw an old woman

filthy and unkempt in her childs house. What should
you do?
a. Advise the woman to visit the hospital
b. Talk to the child of the old woman
c. Call the abuse center for the elderly
d. Perform hygiene care for the old woman
154.A patient has a subcutaneous terbutaline (Brethine)
pump for treatment of preterm labor. Which of the
following findings warrants a call to the physician?
a. Fetal movements are fewer than 12 per
hour
b. The patient feels nervous and jittery
c. The patients pulse is 124 beats per minute
d. Fetal movements are more than 12 per hour
155.The nurse is teaching a client how to perform selfmonitoring blood glucose (SMBG) using a blood
glucose monitor. Which of the following actions, if
performed by the client indicates to the nurse the
need for further teaching?
a. The client lets her hand dangle before
sticking her finger with the lancet
b. The client sticks her finger on the side of
the distal pharynx
c. The client touches the strip with a large
drop of blood from her fingertip
d. The client milks her finger after sticking it
156.A bipolar patient refuses to put down the mop that
he is swinging to threaten other patients and staff.
What information is most important for the nurse to
consider before administering a PRN IM dose of
lorazepam (Ativan)?
a. The patient is harmful to himself
b. The patient is psychotic
c. A restrictive intervention failed
d. The patient is harmful to others
157.A client is admitted to the burn unit with a thirddegree burn to the chest, face, and upper
extremities. During the acute phase (i.e., first 48
hours) of a major burn injury, which assessment
findings should the nurse report immediately?
a. Temperature of 100F
b. Edema of hands
c. Decreased sensation in the extremities
d. Urinary output of 200 ml over 8 hours
158.A 19-month old child weighs 22 pounds and has an
order of 200 mcg digoxin to be given intravenously.
You have a vial of digoxin at a concentration of
0.1mg/ml. how many millilitres of the solution will
you need to deliver the ordered dose?
a. 0.22 mL
b. 0.002 mL
c. 2.0 mL
d. 0.2mL
159.Mrs. Langley has hyperosmolar nonketotic coma with
hyperglycemia. She begins to experience CNS
dysfunction. What is most likely source of this
dysfunction?
a. Adrenal gland tumor
b. Cellular fluid loss
c. Fever
d. Hypoxia
160.The nurse is supervising a care given to clients on a
medical/surgical unit. The nurse should intervene if
which of the following is observed?

a.
b.
c.
d.

A nurse and client wear masks during a

dressing change for the central catheter
used for total parenteral nutrition
A nurse injects insulin through a singlelumen percutaneous central catheter for
client receiving total parenteral nutrition
A nurse applies lip balm to his/ her lips
immediately after performing a blood draw
to obtain specimen
A nurse wears a disposable particulate
respirator when administering rifampicin to
a client withtuberculosis.

161.A patient is in 8 cm dilated, 90% effaced and -3

station when her water breaks. Immediately
thereafter, the fetal heart rate decelerates in the
60s. the nurse knows:
a. This could be a sign of uterine rupture
b. This could be a sign of cord prolapse
c. This is a normal fetal heart pattern
d. This is a normal fetal heart pattern
162.Which statement by a patient with a history of major
depression indicates that he is not maintaining good
health in his current environment?
a. Going back to work, well, its not bad; its
okay.
b. I just dont like going to the movies like I
did before.
c. I cant wait to go to my sons wedding next
weekend. It will be nice to have the whole
family together.
d. I had a great trip to the Smokey Mountains.
It was fun.
163.The nurse knows that which of the following mood
altering drugs is most often associated with an
increased risk for HIV infection related to
intravenous drug use?
a. Benzodiazepines
b. Marijuana
c. Barbiturates
d. Narcotics
164.A 7-year-old child is diagnosed with insulindependent diabetes mellitus. The child and parents
are being taught what should occur if the child
presents with signs and symptoms of hypoglycaemia.
Which statement if made by the parents would
indicate an understanding of the teaching?
a. It is important to decrease the amount of
long-acting insulin.
b. It is important for the child to rest in bed
until the symptoms subside.
c. It is important to increase activity prior to
insulin administration.
d. It is important for the child to eat 4-6
lifesavers candies or drink orange juice.
165.A urinalysis has been obtained on a client who has
been complaining of dysuria, urinary frequency, and
discomfort in the suprapubic area. After evaluating
the results, the nurse should order a repeat
urinalysis based on which of the following findings?
a. Negative glucose
b. RBCspresent
c. No WBCs or RBCs reported
d. Specific gravity 1.018
166.The client is to have EMG. Which of the following is
the correct instruction?
a. Ask the client for allergies to seafoods
b. Tell the patient that he may experience
discomfort because of the needles to be
used
c. Put the patient on NPO 6-8 hours
d. Ask the patient to empty the bladder
167.Indicated use of magnesium sulphate in pregnancy is:
a. To prohibit preterm labor
b. Both prohibit preterm labor and prevent
seizure

c.
d.

To trigger breast milk letdown

To prevent seizures

168.The nurse is caring for a client with perforated

bowel secondary to bowel obstruction. At the time
the diagnosis is made, which of the following should
be a priority in the nursing are plan?
a. Maintain the client in a supine position
b. Notify the clients next of kin
c. Prepare the client for emergency surgery
d. Remove the nasogastric tube
169.Which action would be the first priority when caring
for a client in anaphylaxis?
a. Administer an antibiotic
b. Administering oxygen via face mask
c. Obtaining vascular access
d. Preventing future antigen exposure
170.The home health nurse is performing a follow-up
visit for a 76-year-old man receiving isoniazid (INH)
200 mg every day for 6 months. The nurse would be
most concerned if the client made which of the
following statements?
a. I have blurred vision at times.
b. My legs and knees hurt.
c. My hands and feet tingle.
d. I think I had a migraine yesterday.
171.The nurse is obtaining a history on a client just
admitted to the unit. The client informs the nurse
that any information shared with the nurse during
the interview is to remain confidential. Which of the
following responses by the nurse is best?
a. Ill share any information you give me with
staff members only.
b. If the information you share is important
to your care, Ill need to share it with the
staff.
c. We can keep the information just between
the two of us.
d. I have an obligation to maintain
nurse/patient confidentiality about
anything you tell me.
172.After abdominal surgery, a client is admitted from
the recovery room with intravenous fluid infusing at
100cc/hr. One hour later, the nurse finds the clamp
wide open and notes that the client has received
850cc. The nurse would be most concerned by which
of the following?
a. A CVP reading of 12 and bradycardia
b. Tachycardia and hypotension
c. Dyspnea and oliguria
d. Rales and tachycardia
173.What is the cause of blindness due to diabetic
retinopathy?
a. Haemorrhage
b. Tiny lesions in the tear ducts
c. Acidosis
d. Scar tissue
174.A staff member informs the nurse that his six-yearold child has head lice. It is most important for the
nurse to take which of the following actions?
a. Inspects the staff members head for louse
and nits
b. Inform the staff member that he cannot
care for clients until further notice
c. Request that the staff member contact the
physician
d. Instruct the staff member about how to use
Kwell
175.To help prevent polypharmacy interactions in a client
who is taking multiple prescriptions, what instruction
would the nurse give to the client?
a. Use a dispensing system as a reminder to
take medications on a schedule
b. Inform a family member of the names and
uses of all medications

c.
d.

Bring all medications, including

supplements and herbal remedies to the
doctors appointment
Abstain from taking any over-the-counter
medications in addition to the medication
you are already taking

176.A 7-year-old client is scheduled for a cardiac

catheterization. Which priority nursing assessment
finding to report to the physician?
a. The child has an allergic reaction of hives to
shellfish
b. The child insists on taking a stuffed teddy
bear to the procedure
c. The child has cool lower extremities with
brisk capillary refill bilaterally
d. The child has diminished palpable pedal
pulses bilaterally
177.A 6-month-old infant has returned to the unit from
surgery. Which assessment finding would indicate
that the infant was experiencing pain?
a. The child cries steadily and kicks
b. The child points to the area producing the
pain
c. The child has a rating of 6 on the Faces Pain
Rating Scale
d. The child sleeps soundly, with an increased
pulse rate and decreased blood pressure
178.Which of the following would the nurse see first?
a. Psychotic patient with delusion
b. Severe depression with suicide ideation
c. Patient with anxiety who is agitated
d. Patient with bipolar manic phase
179.A client presents with hypoparathyroidism. Which
assessments will the nurse make with this client?
a. Nephrolithiasis
b. Serum calcium level of 6.8 mg/dL
c. Positive Chvosteks sign
d. Serum phosphorus level of 5.2mg/dL
180.In which situation is the patient most likely to
experience anticipatory grieving?
a. The patient experiences traumatic
amputation of an extremity in an industrial
accident
b. A patient is brought into the Emergency
Room and declared brain dead
c. After diagnostic testing, a patient is
diagnosed with metastatic liver cancer
d. A patient finds out that her symptoms were
from an ectopic pregnancy
181.A nurse notices ventricular tachycardia on the
cardiac monitor at the nurses station and goes to
the clients room. What is the first action the nurse
should take in assisting this client?
a. Start cardiopulmonary resuscitation
b. Check the patients airway
c. Establish unresponsiveness
d. Alert the physician on call
182.The clinic nurse observes that a ten-year-old child
with leukemia has a large bum on her arm and the
bum appears to be oily. The client states that she
touched a hot pan and her mother put cooking fat on
it so it would not blister. The nurse should:
a. Document the findings in the chart
b. Call the physician immediately to report the
injury
c. Teach the client that oil holds germs and
makes infection more likely
d. Wash the burn with soap and water to
remove the oil
183.The nurse is caring for a client postoperatively
following removal of a pituitary tumor. Which
observation would alert the nurse to the possible
development of diabetes insipidus (DI)?
a. Weight gain

b.
c.
d.

Peripheral edema
Urinary output of greater than 200mL/hr
Serum sodium of 150 mEq/L

184.The nurse is making a home visit for a client with an

abdominal wound. When irrigating the draining
wound with a sterile saline solution, which of the
following sequences would be most appropriate for
the nurse to follow?
a. Pour the solution, wash hands and remove
the soiled dressing
b. Wash hands, prepare the sterile field and
remove soiled dressing
c. Prepare the sterile field, put on sterile
gloves, and remove the soiled dressing
d. Remove the soiled dressing, flush the wound
and wash hands
185.A client underwent a cerebral angiogram through the
right femoral site. Which post-procedural nursing
assessments would justify calling the physician?
(SATA)
a. Equal, bilateral radial pulse
b. Bilateral pink, warm toes
c. Blood pressure of 88/52 mmHg
d. Pulse 122
e. Right pedal pulse weaker than left pedal
pulse
f. Respiration 22
g. Intact dressing that needs reinforcement
due to bloody drainage
186.Which factor may contribute to the development of
osteoarthritis? SATA
a. Excessive use of alcohol
b. 20 to 20 years of age
c. Obesity
d. Caucasian or Asian ethnicity
e. Regular strenuous exercise
f. Family history of osteoarthritis
187.An adult client is brought into the Emergency
Deparment in cardiac arrest. Cardiopulmonary
resuscitation (CPR) is being performed. Name the
area where the pulse should be checked.
a. Ulnar or radial pulse
b. Dorsalispedis pulse
c. Brachial pulse
d. Carotid pulse
188.A client has a nasogastric tube in place after
extensive abdominal surgery. The client complains of
nausea. His abdomen is distended and there are no
bowel sounds. The first nursing action should be to:
a. Administer the PRN pain medication and an
antiemetic
b. Irrigate the nasogastric tube with normal
saline
c. Determine if the nasogastric tube is patent
and draining
d. Check the placement of the nasogastric
tube by auscultation
189.Which emergency medication should the nurse
initially administer to a client in pulseless electrical
activity?
a. Lidocaine 4mg/min IV infusion
b. Atropine 1.0mg IV push
c. Epinephrine 1.0mg IV push
d. Amiodarone 400 mg IV push
190.The nurse knows which of the following would have
the greatest impact on an elderly clients ability to
complete activities of daily living (ADLs)?
a. Perseveration
b. Aphasia
c. Mnemonic disturbance
d. Apraxia
191.The nurse is administering furosemide (Lasix) to a
patient who has edema associated with congestive

heart failure. What is the most appropriate

parameter for the nurse to monitor regarding
effectiveness of this drug?
a. Urine specific gravity
b. Serum potassium level
c. Daily weight
d. Abdominal girth measurement
192.A 30-year-old woman is admitted to the hospital with
dry mucous membranes and decreased skin turgor,
the womans vital signs are BP 120/70, temperature
101F (38.3C), pulse 88, respirations 14. Laboratory
tests indicate the serum sodium is 150 mEq/L and
Hct is 48%. The nurse expect the physician to order
which of the following IV fluids?
a. D5NSS
b. 0.45% NaCl
c. 0.9% NaCl
d. Lactated Ringers
193.Which of the following condition are associated with
impaired glucose tolerance (IGT)?
a. Hypoglycaemia and prostatitis
b. Obesity and hypotension
c. Obesity and syndrome X
d. Hypotension and hyperlipidemia
194.You are teaching a patient who is newly diagnosed
with diabetes, how to choose healthy snacks. Of the
following foods, which is the best choice for your
patient?
a. Chocolate chip cookies with nuts
b. Ice cream
c. Buttered popcorn
d. Baked chips and salsa
195.The clinic nurse is obtaining a throat culture from a
client with pharyngitis. It is most important for the
nurse to do which of the following?
a. Quickly rub a cotton swab over both
tonsillar areas and the posterior pharynx
b. Obtain a sputum container for the client to
use
c. Irrigate with warm saline and then swab the
pharynx
d. Hyperextend the clients head and neck for
the procedure
196.Which measures should the nursing care of a client
with hypothyroidism include?
a. Planning frequent rest periods
b. Providing cool environment
c. Encouraging the use of heating pad
d. Provide a low-calorie, high-protein diet
197.The nurse is drawing up a vitamin K injection for a
newborn. What should the dose be?
a. 1-2 mg
b. 0.5-1 mg
c. 10-50 mg
d. 12 mL
198.Which statement by a nurse in response to a patient
would be an example of a reflective question or
comment?
a. How do you feel when you take the
medication?
b. Tell me what occurred first- did your
symptoms occur before or after you took
the medication?
c. What time do you take your medication?
d. Youve been upset about your blood
pressure.
199.A patient undergoing hip replacement surgery who is
at risk for the development of deep vein thrombosis
is receiving dalteparin (Fragmin). Which statement
correctly describes the administration technique for
the medication?
a. Use an 18-guage, 1 inch needle to
administer the drug

b.
c.
d.

Inject the medication into the muscle

within 2 inches of the umbilicus
Aspirate prior to administering the
medication
Administer the medication by subcutaneous
route

200.The nurse is caring for patients in an acute renal

care facility. The nurse would identify which of the
following patients as a likely candidate for
developing acute renal failure?
a. A young female with recent ileostomy due
to ulcerative colitis
b. A middle-aged male with elevated
temperature and chronic pancreatitis
c. A teenager in hypovolemic shock following a
crushing injury to the chest
d. Child with compound fracture on the right
femur and massive laceration of the left
arm

14. C. Notify the if there is arm or hand numbness,

coldness, tingling, swelling, or pain
15. C.

ANSWER
1.

C. Compulsive behavior is an unconscious attempt

to control and/or relieve the tension and anxiety the
client is experiencing It is not a manipulation on the
clients part. Client is not subject to depression but
to high levels of anxiety.

2.

D. Infant suckling cause the posterior pituitary to

release oxytocin, which is a hormone that contracts
the uterus.

3.

A. Options B&D are symptoms of hyperthyroidism.

Option C are symptoms of hypothyroidism
(myxedema).

4.

B. ECG changes can indicate potentially lethal

arrhythmias such as ventricular fibrillation, which
can occur in hyperkalemia.

5.

A. Graves disease results from an increased

production of thyroid hormone. It is state of
hypermetabolism. The increased metabolic rate
generates heat and produces tachycardia and fine
muscle tremors. Patients are encourage to have
frequent rest periods, and are advised to avoid
strenuous physical activity. Management include the
use of antithyroid drugs (propylthiouracil or
Tapazole), radioactive iodine, or surgical removal of
a portion of the gland.

6.

C. Early signs of lithium toxicity are Fine tremors,

nausea, vomiting, diarrhea. Late signs include
Ataxia, confusion, seizures

7.

A, D, E, F. The presence of frankly bloody emesis

(hematemesis) suggests moderate to severe bleeding
that may be ongoing, whereas coffee-ground emesis
suggests more limited bleeding. Melena may be seen
with variable degrees of blood loss, being seen with
as little as 50 mL of blood. Hematochezia (red or
maroon blood in the stool) is usually due to lower GI
bleeding. However, it can occur with massive upper
GI bleeding, which is typically associated with
orthostatic hypotension.

8.

B.

9.

B. Consolidation will result in diminished breath

sounds over the lobes involved. Wheezing results
from constricted airways such as in asthma.
Bronchovesicular breath sounds are normal lung
sound. Hyperresonance results from percussing an
excessively air-filled lung or pleural space.

16. A. Four main methods of treatment exist for a

patient with Pagets disease, pharmacological
therapy using either bisphosphonates or calcitonin;
pain management using analgesics; surgery; and nonpharmacological therapy (focusing mainly on physical
therapy as a means of improving muscle strength to
help control some types of pain).
17. C. Fine macular rash during ciprofloxacin
administration indicates hypersensitivity reaction,
should stop medication and notify the physician.
Option A does not warrants an immediate concern.
Option B, PTT is within normal limits, should give
medication. Option D, should decrease rate to
prevent irritation of the vein.
18. A.
19. A. Condition is often called spastic bowel disease.
Options B & C refer to inflammatory bowel disease
such as ulcerative colitis or Crohn's disease. Bloody
stools do not occur.
20. D, E. Clots or fresh blood in the nose or throat,
frequent swallowing, clearing of the throat, and
vomiting of dark blood are indications of possible
bleeding. Check the back of the patient's throat with
a flashlight for trickling of blood. Decreased BP,
tachycardia, pallor, and restlessness are hallmark
signs of hemorrhage and should be reported to the
surgeon immediately.
21. C. Carvedilol is a nonselective beta-adrenergic
antagonist that blocks the action of beta1 receptors
in the heart and the action of beta2 receptors in the
lung, smooth and skeletal muscles. Blocking the
beta1 receptor leads to deacreased heart rate,
contractility and velocity of impulse conduction in
the atrioventricular node. Beta2 receptors blockade
can result in bronchoconstriction and inhibition of
glycogenolysis. Because of this drugs effect on the
heart, the nurse should assess the patients current
pulse and blood pressure before administering
carvedilol. The prescriber should be contacted if
bradycardia or hypotension is identified prior to
administration of the drug. Carvedilol is
administered orally.
22. B. First signs of acute rejection are usually a rash,
burning, and redness of the skin on the palms and
soles. This can spread over the entire body. Other
symptoms include nausea, vomiting, stomach
cramps, diarrhea (watery and sometimes bloody),
loss of appetite, yellowing of the skin and eyes
(jaundice), abdominal (belly) pain, weight loss.
23. A.

10. C. Atropine has a vagolytic effect as well as blocks

muscarinic responses and has selective depression of
central nervous system. Benadryl is an H-1 receptor
antagonist and antihistamine with anticholinergic
activity and does not protect against vagal
bradycardia. Adrenalin is a catecholamine that
constricts bronchioles and inhibits histamine release,
and Prozac is a antidepressant.

24. D. Muscles are generally strongest in the morning,

and activities involving muscle activity should be
scheduled then. There is no decrease in sensation
with MG, and muscle atrophy does not occur because
muscles are used during part of the day.

11. D.

26. B. Magnesium sulfate is a central bervous system

depressant and relaxes smooth muscles. Adverse
effects include flushing, depressed respirations,
depressed deep tendon reflexes, hypotension,
extreme muscle weakness, decreased urinary
output, pulmonary edema and elevated serum
magnesium levels.

12. C. The suicide of her son puts this patient at high

risk of suicide. This risk is exacerbated by the
betrayal of her husband and best friend.
13. C. *

25. B.

27. B. Stress ulcers or Curling's ulcers are acute

ulcerations of the stomach or duodenum that form
following the burn injury.
28. C. Olanzapine (Zyprexa) is an atypical antipsychotic
drug given to patients with schizophrenia. Key
treatments for obsessive-compulsive are
benzodiazepines and SSRIs. Fluoxetine (Prozac) and
other SSRIs are given to patients with bulimia
nervosa. Seroquel is an atypical antipsychotic.
Buspar is an anxiolytic drug.
29. B. Raynauds disease is characterized by attacks of
vasospasms in the small arteries and arterioles of the
fingers and sometimes the toes. The disease
primarily affects young women and can be triggered
by exposure to cold.
30. D. Utilization of an MDI requires coordination
between activation and inspiration; deep breaths to
ensure that medication is distributed into the lungs,
holding the breath for 10 seconds or as long as
possible to disperse the medication into the lungs,
shaking up the medication in the MDI before use, and
a sufficient amount of time between puffs to provide
an adequate amount of inhalation medication.

43. A. Dye is injected into subarachnoid space before an

x-ray of spinal cord and vertebral column to assist in
identifying spinal lesions; if client is allergic to dye,
there is a major safety issue. It is important that
client drink extra fluids AFTER the test to replace
CSF lost during test and to flush out the dye. Option
C is appropriate for MRI.
44. D. Client is under constant observation; must not be
left alone for any reason
45. C.
46. C. Stridor on exhalation is a hallmark of respiratory
distress, usually caused by obstruction resulting from
edema. One emergency measure is to remove the
surgical clips to relieve the pressure. In some
settings, this may be a nursing action; in other
settings, this is a physician function. Emergency
intubation also may be necessary.
47. A.

32. B.

48. B. Option A & D, reveals normal values: BUN 718

mg/dL; creatine 0.61.2 mg/dL; AST (formerly
SGOT) 820 U/L, ALT (formerly SGPT) 820 U/L,
bilirubin 0.11.0 mg/dL . Amphotericin B causes
renal and liver toxicity. Check liver and renal
function studies weekly, notify the physician if
elevated. Option C are not side effects of the
medication.

33. C.

49. B.

34. B. The pathology behind PIH is a fluid shift that

occurs from the vasculature to the tissues, which
causes edema and leads to an increase in
hematocrit.

50. D.

31. C.

35. A.
36. C.
37. A. SIADH is a condition in which the client has
excessive levels of antidiuretic hormone (ADH) and
cant excrete the diluted urine. Therefore, the
client retains fluids. This disorder causes a dilutional
hyponatremia.
38. A.
39. A, C, E. An endoscopic retrograde
cholangiopancreatography is anendoscopic test that
provides radiographic visualization of the bile and
pancreatic ducts. Postprocedural care after the ERCP
include monitoring the vital signs and maintaining an
NPO status until the gag reflex returns. The client
probably received sedating medication before the
procedure; consequently, lethargy is expected. A
local anesthetic is sprayed into the clients throat, so
it is possible that the gag and cough reflexes will not
be present. The client should be monitored for signs
of cholangitis and perforation, which include fever,
abdominal pain (especially in the RUQ), hypotension
and tachycardia.
40. D. Ibandronate (Boniva) is a bisphosphonate drug. In
giving such drugs the nurse should instruct the client
to swallow the whole tablet, it should not be
chewed. It should be taken in the morning on an
empty stomach with large glass of water (6-8oz) and
wait at last 30 minutes before eating or lying down.
Make sure the client has adequate intake of Vitamin
D. Instruct the client to report any signs and
symptoms of gastric reflex or pain.
41. B.
42. C. The airway is compromised by the bleeding in the
esophagus and aspiration easily occurs.

51. A, C, F.
52. A. Robust means strong and healthy. Pulse pressure
of 40 is normal. All other options reveal abnormal
assessment.
53. C, E, F.
54. C. This patient has experienced a loss (job) that is
contributing to his feelings of uselessness to his
family. The diagnosis of situational low self-esteem is
the most appropriate diagnosis for this patient. The
North American Nursing Diagnosis Association
(NANDA) definition for the nursing diagnosis is the
development of a negative perception of self-worth
in response to a current situation.
55. B. Antipyretics relieve the combination of side
effects. Ice bag is dangerous to both skin integrity
and overall temperature control. Option D is
unnecessary unless indicated for another reason.
56. D. Cushing's triad is systolic hypertension with a
widening pulse pressure, bradycardia with a full and
bounding pulse, and slowed respirations. The rise in
blood pressure is an attempt to maintain cerebral
perfusion, and it is a neurologic emergency because
decompensation is imminent.
57. C. Several strains of the human papillomavirus (HPV)
are associated with cervical cancer. Antibiotics are
not used for viral infections. Douches will not
prevent recurrence of the disease. Tampons would
not be a problem as in toxic shock syndrome.
58. B.
59. B.
60. B. Environments with increased numbers of children
(day care) more likely to promote infections due to
close living conditions and increased likelihood of
disease transmission. Option A & D do not pose a
problem or solution regarding gastroenteritis.
Neighbourhood is a possible source of infection, but
not as likely as a day care center.

61. A.

87. D.

62. B. Position of the trachea should be evaluated; with

a tracheal shift, an increase in pressure could occur
on the operative side and could cause pressure
against the mediastinal area. On the surgical side,
breath sounds will be absent. Sputum is important to
observe but not as high a priority. Pulse pressure
does not relate to the situation
63.
64. A.

88. D. The patient is at risk for lymphedema and

infection if blood pressures or venipuncture are done
on the right arm. The patient is taught to use the
PCA as needed for pain control rather than at a set
time. The nurse allows the patient to examine the
incision and participate in care when the patient
feels ready. Permanent breast prostheses are usually
obtained about 6 weeks after surgery.

65. D.
66. C.
67. D.
68. A. Potassium chloride must be diluted and
administered at a rate no faster than 20mEq/hr
69. C. Nitroglycerin patch should be removed before the
test. Dentures are removed removed before the test.
Option B, results are within normal limits. It is
unnecessary check capillary refill.
70. A. Delusion of perseceution is a strongly held belief
that is not validated bu reality, for example, the
idea that his brother is trying to steal his property is
not validated by reality. Delusion of reference is a
false belief that public events or people are directly
related to the individual.
71. C.
72. A.

89. C.
90. A. After a total hip replacement, it is important to
maintain the hip in a state of abduction to prevent
dislocation of the prosthesis. Use of an abduction
pillow or splint will not prevent the formation of
sacral pressure ulcers. An abduction pillow may also
be used to keep the legs shoulder width apart and to
prevent rotation of the hips, and avoid crossing the
leg beyond the midline of the body (e.g. not crossing
the leg over the other leg).
91. A. Among the 4 women, the least stable patient is
the patient experiencing unilateral dull abdominal
pain. The pregnant woman needs to be evaluated
immediately for ectopic pregnancy. Option B is
expected during first trimester of pregnancy. Option
C is symptomatic of threatened abortion, should be
instructed to decrease activity. Option D symptoms
suggest of spontaneous abortion and should be
instruct client to pads. Ectopic pregnancy needs
more emergent intervention as compared to
abortion.

73. C. During a sickle cell crisis, increasing the transport

and availability of oxygen to the body's tissues is
paramount. Administering a high volume of
intravenous fluid and electrolytes to help
compensate for the acidosis resulting from
hypoxemia associated with sickle cell crisis is one
way to accomplish this. Fluid administration also
helps overcome dehydration, a possible predisposing
factor common in clients with sickle cell crisis.

92. C. Instillation of erythromycin into the neonates

eyes provides prophylaxis for opyhalmia neonatorum
or neonatal blindness caused by gonorrhoea in the
mother. Erythromycin is also eefctive in the
prevention of infection and conjunctivitis from
Chlamydia trachomatis. The medication may result
in redness of the neonates eyes, but this redness
will eventually disappear. Erythromycin ointment is
not effective in treating neonatal chorioretinitis
from cytomegalovirus. No effective treatment is
available for a mother with cytomegalovirus.

74. D.

93. B.

75. C.

94. D. EKG changes in hyperkalemia: Peaked T waves;

Widened QRS complexes; prolonged PR intervals;
Flat P waves

76. B. Extrapyramidal reactions include movement

disorders such as dystonia, tardive dyskinesia, and
pseudoparkinsonism.

95. B.

77. A.

96. B.

78. A.

97. C.

79. D.

98. D. The temperature range during which the basal

metabolic rate of the baby is at a minimum, oxygen
utilization is least and baby thrives well is known as
'Thermo- neutral range of temperature' or 'Neutral
Thermal Environment'. For each baby, this range of
temperature varies depending on gestational age.

80. D.
81. B.
82. A. ECG monitoring of acute coronary syndrome:
features that increase the likelihood of infarction
are: new ST-segment elevation; new Q waves; any
ST-segment elevation; new conduction defect. Other
features of ischaemia are ST-segment depression and
T-wave inversion.
83. A.
84. A.
85. B.
86. B.

99. A. first dose of the DPT may be given at two months,

the second is given around four months. MMR is given
at 15 months. Polio is given at two and four months
and again at 12 to 18 months. Smallpox vaccine is no
longer recommended.

113.A. Ostomy bags should be changed at least once a

week or when seal arpunf stoma is loose or leaking;
during change of bag isa good time for stoma and
skin to be closely inspected. Client should be
encouraged to participate and should foster
independence.
114.A.
115.A.
116.A. Patient has not lost civil right to use phone.
Patient is able to use phone unless otherwise
indicated by court order or physicians order.
117.D. Garlic, a lipid lowering-agent, increase bleeding
potential with aspirin, NSAIDs and warfarin.

100.D. Diagnosis of rheumatic fever is based on the Jones

criteria and positive laboratoty tests for: Increased
erythrocyte sedimentation rate; positive C-reactive
protein; positive antistreptolysin-O titer; positive
throat culture for group A beta haemolytic
streptococci; prolonged PR and QT intervals,
revealed by ECG.
101. B. The absence of spontaneous cough and presence
of drooling and agitation are cardinal signs
distinctive of epiglottitis.
102.B. Hallmark of aseptic technique is handwashing.
Client should use only the prescribed medications on
the wound.
103.D.
104.B. Take the drug with food or after meals if GI upset
occurs. Do not cut, crush, or chew sustained-release
products. Report ringing in the ears; dizziness,
confusion; abdominal pain; rapid or difficult
breathing; nausea, vomiting, bloody stools, easy
bruising, gum bleeding (related to aspirins effects
on blood clotting).
105.B. Fontanelle should feel soft and flat; fullness or
bulging indicates increased intracranial pressure.
Umbilical cord falls off within 1 to 2 weeks; no tub
baths until the cord falls off. Normal healing of
cirucmcision, don't remove exudate; clean with
warm water. motor reflex is normal; disappears after
3 to 4 months.
106.D.
107.C. Principles for radiation therapy are time,
distance, shielding; nurse should decrease the time
spent in close proximity to the client. All visitors are
restricted with regard to the distance they should be
from the client. Appropriate shielding (lead aprons)
is to be used when the nurse has to spend any length
of time at a close distance, not just for routine care.
108.C.
109.C. Nystatin is given for candida infections such as
oral thrush. A common side effect is diarrhea.
110.B.
111.A. Signs and symptoms of abdominal aortic aneurysm
include: diminished femoral pulses, lower back and
abdominal pain, pulsatile abdominal mass, bruit over
site, BP difference between extremities, peripheral
ischemia.
112.D. Patient is at risk for peritonitis, and should be
assessed for further symptoms of infection. Option A
reveals small amount of bleeding and does not
indicate acute bleeding. Option B suggests expected
outcome. Option C indicates resolution.

118.D. A goal when caring for patients with spinal cord

injuries is to promote their adjustment to the injury
and their independence. A patient who is using
modified feeding utensils at every meal is
demonstrating an attempt at independence for the
functional activity of eating. The patient's statement
recognizes that the activity is one that requires
continued work, but progress is being made toward
the goal of developing as much independence as
possible with eating.
119.C. Other options suggest exacerbation of the
disease.
120.A.
121.D. Water should not be allowed to stand in
containers, such as respiratory or suction equipment
because this could act as a culture medium.
122.A. Neurogenic shock is characterized by areflexia. In
neurogenic shock, vasodilation occurs as a result of a
loss of balance between parasympathetic and
sympathetic stimualtaion. The patient experiences a
predominant parasympathetic stimulationthat causes
vasodilation lasting for an extended period. It is
manifested by hypotension, due to a reduction in
systemic vascular resistance and venous return;
warm, dry skin; bradycardia, due to dominance of
the parasympathetic system (vagus nerve); flaccid
paralysis, including bowel and bladder; hypothermia,
due to vasodilation.
123.C.
124.B. By administering Librium, you will prevent
delirium tremens that can possibly harm during the
process.
125.A, D, E, F.
126.A. Open Kaposis sarcoma lesions should be cleaned
and dressed daily to prevent secondary infection.
Warm tub bath is not done because of risk of
secondary skin infection. It is important to keep the
skin clean to prevent secondary skin infection but
should be covered due to open areas. Diluted
povidone-iodine is the treatment for herpes simplex
virus abscess, not Kaposis sarcoma.
127.C. Assessment of the dressing should be checked on
admission to the room and frequently for the next
several hours. Option A is an Implementation,
complete assessment first. Option B is an assessment
but determine what is happening to the patient
now. Option D is an inappropriate assessment, it is
too soon for infection to occur secondary to surgery.
128.C. Polio vaccine contains live virus and should not be
given to children who are immunocompromised.
129.A. Unsteady gait, slurred speech, nausea, vomiting,
diarrhea, thirst, and coarsening of hand tremors
indicate lithium toxicity.

130.D. Hypertensive crisis, an adverse effect of this

medication, is characterized by hypertension,
frontally radiating occipital headache, neck stiffness
and soreness, nausea, vomiting, sweating, fever and
chills, clammy skin, dilated pupils, and palpitations.
Tachycardia, bradycardia, and constricting chest
pain may also be present. The client is taught to be
alert to any occipital headache radiating frontally
and neck stiffness or soreness, which could be the
first signs of a hypertensive crisis. Hypertensive crisis
is treated with (Nifedipine) Procardia.
131.D.
132.A. Tracheostomy set is the most important for the
client's safety due to risk for laryngospasm.
133.B.
134.D.
135.C. Extrapyramidal side effects resulting from this
medication include akathisia (motor restlessness),
dystonias (protrusion of tongue, abnormal
posturing), pseudoparkinsonism (tremors, rigidity),
and dyskinesia (stiff neck, difficulty swallowing). The
dosage may need to be decreased because of side
effect of medication; antiparkinsonian drug such as
Cogentin may be ordered. Option B is not accurat,
Thorazine is an antipsychotic medication.
136.D.
137.B. You should not cut extended-release tablets in
half.
138. A. The patient may be experiencing hypocalcemia.
139.A, C, D, E.
140.C.
141.B. Postural hypotension can be a result of dizziness
owing to the use of low-potency antipsychotics such
as chlorpromazine or thioridazine.
142.A,B,C,E. Hemolytic Reaction is a type of
complication of blood transfusion is caused by
infusion of incompatible blood products. Assessment
include Low back pain (first sign). This is due to
inflammatory response of the kidneys to
incompatible blood; Chills; Feeling of fullness;
Tachycardia; Flushing; Tachypnea; Hypotension;
Bleeding; Vascular collapse; Acute renal failure.
143.D. Droplet precautions used for organisms that can
be transmitted by face-to-face contact, door may
remain open. Option A&B require contact
precautions with no mask. Option C requires
standard precautions.
144.C. Naloxone is a narcotic antagonist that can reverse
the effects, both adverse and therapeutic, of opioid
narcotic analgesics. Morphine is an opioid narcotic
analgesic that can depress respiration.
145.B.
146.A. To implement a behavior modification plan
successfully, all staff members need to be included
in program development, and time must be allowed
for discussion of concerns from each nursing staff
member; consistency and follow-through is
important to prevent or diminish the level of
manipulation by the staff or client during
implementation of this program.
147.A.
148.B

149.C.
150.C. Alteplase is a tissue plasminogen activator which
induce fibrinolysis that causes bleeding.
151.A. Lamotrigine, marketed in the US and most of
Europe as Lamictal by GlaxoSmithKline, is an
anticonvulsant drug used in the treatment of
epilepsy and bipolar disorder. It is also used off-label
as an adjunct in treating depression. For epilepsy, it
is used to treat focal seizures, primary and
secondary tonic-clonic seizures, and seizures
associated with Lennox-Gastautsyndrome.
152.C. Support groups of people who have suffered
similar acts of violence can be helpful and
supportive to teach clients how to deal with the
traumatizing situation and the emotional aftermath.
Other options are reasonable recommendations to
begin using in a systematic desensitization program
after the crisis is alleviated.
153.C. Vitamin K food sources are green leafy
vegetables, cauliflower and cabbage.
154.
C. The nurse must immediately call and
report the suspected abuse. Failure to report abuse
is a misdemeanor.
155.C.
156.D. Milking forces interstitial fluid to mix with
capillary blood and dilutes the blood. Dangling helps
facilitates venous congestion. Sticking on the side is
less painful that the center of the fingertip. Blood
should sit on the strip like a raindrop, smearing
alters the reading.
157.C. Use the least restrictive interventions in
ascending order.
158.D. Acute phase of burn injury occurs from beginning
of diuresis to the near completion of wound closure
Characterized by fluid shift from interstitial to
intravascular. Urinary output of less than 30ml/hr
should reported to the physician.
159.C. 1 milligram = 1000 mcg
160.B. In HHNS, CNS depression, disorientation or mental
confusion, seizures, and coma are caused by
intracellular dehydration and hyperosmolarity. CNS
dysfunction worsens as serum osmolarity rises.
161.C. Applying lip balm or handling contact lenses is
prohibited in work areas where exposure to
bloodborne pathogens may occur. Option A
demonstrates appropriate procedure, prevents
airborne contamination. Insulin is the only
medication that can be given, compatible with TPN.
Use airborne precautions for TB, private room with
negative air pressure, minimum of six exchanges per
hour.
162.B.
163.B. Anhedoniathe loss of interest and pleasure in
activitiesis a sign of depression.
164.D. Narcotics are most often used intravenously
165.D. Candy or another simple sugar is carried and used
to treat mild hypoglycemia episodes.
166.C. With the clients complaints, WBCs and RBCs
should be present; WBCs are a response to the
inflammation process and irritation of the urethra;
RBCs are increased when bladder mucosa is irritated
and bleeding. Glucose increases during the
inflammation process; it is not a primary component
in determining urinary tract infections.

167.A.
(B.) Electromyography (EMG) assesses electrical
activity associated with nerves and skeletal muscles.
Needle electrodes are inserted to detect muscle and
peripheral nerve disease. You should inform the
patient that pain and discomfort are associated with
insertion of needles. There is no risk of electric
shock with this procedure.
168.B. Magnesium Sulfate is used to reduce preterm
labor contractions and prevent seizures in PreEclampsia
169.C.

the immediate problem of cleansing the wound.

Reporting the physician is unnecessary unless signs of
wound infection is noted.
184.C.
185.B. Handwashing should be done prior to beginning
any procedure, especially irrigating a wound. Using
sterile gloves to remove the dressing would
contaminate them.
186.D,E,G.
187.C,D,F.

171.C. Isoniazid/INH can causes peripheral neuritis. Vit

B6/Pyridoxine is given.

188.D. During CPR, the carotid artery pulse is the most

accessible and may persist when the peripheral
pulses (radial and brachial) no longer are palpable
because of decreases in cardiac output and
peripheral perfusion.

172.B. The nurse is obligated to share client information

with personnel directly involved with the clients
care. The nurse must never agree to keep
information confidential without knowing the
content of the information. The nurse is not
obligated to report information that is not relevant
to the clients care or well-being.

189.C. Should first assess if the tube is open and draining

to determine if there is a problem with the
nasogastric tube; if it is patent and draining it does
not need to be irrigated. Option A & B, may be
carried out after the patency of the tube is
determined. Patency should be checked first by
aspirating stomach contents, not by auscultation.

173.D. Indicates cardiovascular fluid overload.

190.C. The mainstay of drug therapy for PEA

is epinephrine 1 mg every 35 minutes.

170.B.

174.A. Diabetic retinopathy leads to development of

microaneurysms and intraretinal haemorrhage.

191.D.

175.A. Observe for movement (louse) or small whitish

oval specks that adhere to the hair shaft (nits); treat
with gamma-benzene hexachloride (Kwell). Confirm
the presence of lice before excluding from duty; if
lice present, exclude from patient care until
appropriate treatment has been received and shown
to be effective. Assessment should be done first.
Apply Kwell shampoo to dry hair and work into lather
for 45 minutes

192.C.

176.C. Polypharmacy means that multiple medications

have been prescribed.

195.D.

193.B. Hypotonic solution, shifts fluid into intracellular

space to correct dehydration. Hypertonic solutions
are contraindicated in dehydration. Isotonic solutios
are not best with dehydration. Lactated Ringers is
an isotonic solution used to replace electrolytes.
194.C.

179.B.

196.A. To obtain a throat culture specimen, the nurse

puts on clean gloves, then inserts the swab into the
oropharynx and runs the swab along the tonsils and
areas on the pharynx that are reddened or contain
exudate. The gag reflex, active in some clients, may
be decreased by having the client sit upright if
health permits, open the mouth, extend the tongue,
and say "ah," and by taking the specimen quickly.

180.C.

197.D.

181.C. Grief can be classified as acute, anticipatory, or

pathologic. Anticipatory grief is associated with the
anticipation of a death or loss that has yet to take
place. A patient who is newly diagnosed with liver
cancer is most likely to experience anticipatory
grieving when anticipating death.

198.B.

177.A. People who have an allergy to shellfish or iodine

may experience an allergic reaction to the contrast
dye.
178.A.

182.C.
183.D. Because leukemic clients are immunosuppressed,
they are more susceptible to infections; cooking fat
applied to an open wound increases the possibility of
infection; burns should be rinsed immediately with
tap water to reduce the heat in the burn.
Documentation is done later, and does not address

199.D. The statement "You've been upset about your

blood pressure" is a reflective comment that
describes the patient's feelings. A reflective
comment repeats what a patient has said or
describes the person's feelings. It is used by the
nurse to encourage the patient to elaborate on the
topic.
200.D. Dalteparin is given by subcutaneous (under the
skin) injection, usually in the lower abdominal area.
201.C.