Monday, August 4, 2014

Practice Test - Questions

1.  A client seeks treatment in a physician’s office for unsightly varicose veins, and sclerotherapy is recommended. Before leaving the examining room, the client says to the nurse, “Can you tell me again how this sclerotherapy is done?” In formulating a response, the nurse incorporates the knowledge that sclerotherapy consists of

  1. Injecting an agent into the vein to damage the vein wall and close the vein off.
  2. Tying off the vein at the upper end to prevent statis from occurring.
  3. Tying off the vein at the lower end to prevent statis from occurring.
  4. Surgical removal of the varicosity.

2.  Which of the following measures would the nurse institute to help minimize joint pain in a child with rheumatic fever?
  1. Massaging the affected joints.
  2. Applying ice to the affected joints.
  3. Limiting movement of the affected joints.
  4. Encouraging progressive weight bearing.

3.  A 43-year-old man is transferring a load of firewood from his front driveway to his backyard woodpile at 10 a.m. when he experiences a heaviness in his chest and dyspnea. He stops working and rests, and the pain subsides. At noon, the pain returns. At 1:30 p.m., his wife takes him to the emergency department. Around 2 p.m., the emergency department physician diagnoses an anterior myocardial infarction (MI). The nurse should anticipate which orders by the physician?

  1. Streptokinase, aspirin, and morphine sulfate administration
  2. Morphine administration, stress testing, and admission to the cardiac care unit
  3. Serial liver enzyme testing, telemetry, and a lidocaine infusion
  4. Sublingual nitroglycerin, tissue plasminogen activator (tPA), and telemetry

4.  A client is admitted to the hospital for treatment of Prinzmetal's angina. When developing the client's plan of care, the nurse should remember that this type of angina is triggered by:

  1. coronary artery spasm.
  2. an unpredictable amount of activity.
  3. activities that increase oxygen demand.
  4. an unknown source.

5.  Shortly after being admitted to the coronary care unit with an acute myocardial infarction (MI), a client reports midsternal chest pain radiating down the left arm. The nurse notices that the client is restless and slightly diaphoretic, and measures a temperature of:
  1. Risk for imbalanced body temperature
  2. Decreased cardiac output
  3. Anxiety
  4. Acute pain

6.  A nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis of the right leg. The nurse develops the plan expecting that the physician will prescribe which of the following?

  1. Maintain the affected leg in a dependent position.
  2. Apply cool packs to the affected leg for 20 minutes for every 4 hours.
  3. Maintain bed rest.
  4. Administer a narcotic analgesic every 4 hours around the clock.

7.  A client with severe angina and electrocardiogram changes is seen by a nurse practitioner in the emergency department. In terms of serum testing, it's most important for the nurse to order cardiac:

  1. creatine kinase.
  2. lactate dehydrogenase.
  3. myoglobin.
  4. troponin.

8.  Which of the following findings is suggestive of myocardial infarction (MI)?

  1. Elevated serum cholesterol value.
  2. Elevated creatine phosphokinase (CPK) value.
  3. Below-normal erythrocyte sedimentation rate.
  4. Elevated white blood cell count.

9.  A client has developed atrial fibrillation, with a ventricular rate of 150 beats per minute. A nurse assesses the client for

  1. Hypotension and dizziness.
  2. Nausea and vomiting.
  3. Hypertension and headache.
  4. Flat neck veins.

10.  Treatment for Raynaud's disease includes:

  1. avoiding cold and stress.
  2. vasodilator drug therapy.
  3. amputating the affected hand.
  4. removing the blood clot.

11.  A client is being discharged from the hospital after being treated for infective endocarditis. The nurse provides the client with which discharge instructions?

  1. Take acetaminophen (Tylenol) if the chest pain worsens.
  2. Use a firm-bristle toothbrush and floss vigorously to prevent cavities.
  3. Take antibiotics until the chest pain is resolved fully.
  4. Notify all health care providers of the history of infective endocarditis before any invasive procedures.

12.  The nurse recognizes that a couple who have a newborn with Erb's palsy have an accurate understanding of their infant's prognosis when they state:

  1. "This a progressive disease with no cure."
  2. "A year of physical therapy will be necessary."
  3. "Correction can be achieved only through surgery."
  4. "Complete recovery should occur in about 3 months."

13.  A nurse is providing discharge teaching to the family of an elderly patient who is confused and is taking several oral medications. which of the following instructions should be given priority?

  1. Administer medications with meals
  2. Withhold medications that the patient refuses
  3. Supervise the patient's medication administration
  4. Allow the patient to self-medicate when possible

14.  The nurse has given a client a nitroglycerin tablet sublingually for angina. Which of the following vital signs should be assessed following administration of nitroglycerin?

  1. Pulse rate.
  2. Skin color.
  3. Respiratory rate.
  4. Blood pressure.

15.  A nurse is assigned to care for a client with a cardiac disorder and is told that the client has an alteration in cardiac output. The client plans care, understanding that the heart normally sends out how many liters of blood per minute to the body?

  1. 2
  2. 5
  3. 10
  4. 15

16.  Treatment of sickle cell crises includes the application of:

  1. A heating pad to the joints
  2. An ice pack to the joints
  3. A CPM device to the lower leg
  4. A TENS unit to the back

17.  An adult client has been defibrillated 3 times unsuccessfully for ventricular fibrillation, and cardiopulmonary resuscitation is resumed. The nurse concludes that cardiopulmonary resuscitation is being administered most effectively by noting that:

  1. The ratio of compressions to ventilations is 5:1.
  2. Respirations are given at a rate of 12 breaths per minute.
  3. The chest compressions are given at a depth of 1 ½ to 2 inches.
  4. The carotid pulse is palpable with each compression.

18.  A client with refractory angina is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The cardiologist orders an infusion of abciximab (ReoPro). Before beginning the infusion, the nurse should ensure the client has:

  1. negative history of tonic-clonic seizures.
  2. ampule of naloxone (Narcan) at the bedside.
  3. continuous electrocardiogram (ECG) monitoring.
  4. up-to-date activated partial thromboplastin time (APTT) result in his record.

19.  A client with a history of hypertension has been prescribed triamterene (Dyrenium). The nurse determines that the client understands the impact of this medication on the diet if the client states to avoid which of the following fruits?

  1. Apples
  2. Pears
  3. Bananas
  4. Cranberries

20.  After having trouble breast-feeding, a 6-week-old female infant exhibits dry scaly skin and a protruding tongue. A diagnosis of congenital hypothyroidism is made. The mother asks the nurse why the child was not diagnosed with this condition at birth. Which of the following would be the nurse's best response?

  1. "We had the results of the newborn screen, but you did not bring the baby in for the 2-week checkup."
  2. "Your baby had little need for thyroid hormone until she was 1 month old."
  3. "Newborns generally receive enough thyroid hormone from the mother to get by the first few weeks."
  4. "We could not reach you at home to give you the results of tests taken at birth."

21.  A client is scheduled to begin therapy with acetazolamide (Diamox) for the management of glaucoma. Before initiating therapy the nurse asks the client about a history of allergy or sensitivity to

  1. Corticosteroids.
  2. Nonsteroidal antiinflammatory agents.
  3. Penicillin.
  4. Sulfa drugs.

22.  Nursing care for a client includes removing elastic stockings once per day. What is the rationale for this intervention?

  1. To increase blood flow to the heart
  2. To observe the lower extremities
  3. To allow the leg muscles to stretch and relax
  4. To permit veins in the legs to fill with blood

23.  A client with a myocardial infarction (MI) develops pulmonary crackles and dyspnea. A chest X-ray shows evidence of pulmonary edema. The specific type of MI the client had is most probably:

  1. anterior.
  2. posterior.
  3. lateral.
  4. inferior.

24.  A client with myocardial infarction is experiencing new, multiform premature ventricular contractions. Knowing that the client is allergic to lidocaine hydrochloride, the nurse plans to have which of the following medications available for immediate use?

  1. Digoxin (Lanoxin)
  2. Metoprolol (Lopressor)
  3. Verapamil (Isoptin)
  4. Procainamide (Pronestyl)

25.  A newborn with a cleft lip is fed with a special nipple. To minimize regurgitation of the feedings the nurse instructs the mother to:

  1. Give the baby the thickened formula as ordered
  2. Hold and burp the baby frequently while feeding
  3. Lay the baby on the side with the bottle firmly propped
  4. Feed the baby while sitting the baby up in an infant seat

26.  A client with coronary artery disease is scheduled to have a diagnostic exercise stress test. The nurse plans to include which of the following items in the client teaching about this procedure?

  1. Avoid cigarettes for 30 minutes before the procedure.
  2. Wear loose clothing with a shirt that buttons in front.
  3. Eat breakfast just before the procedure.
  4. Wear firm, rigid shoes such as work boots.

27.  The nurse is performing an assessment on a client admitted to the hospital who was diagnosed with toxic shock syndrome. Which of the following assessment questions would assist in eliciting more specific data regarding the cause of this syndrome?

  1. “Have your menstrual periods been irregular?”
  2. “Do you use tampons during your menstrual period?”
  3. “Have you been consuming a high intake of green, leafy vegetables?”
  4. “Did you start your menses at an early age?”

28. A client is receiving a contagious intravenous infusion of heparin sodium to treat deep vein thrombosis. The client’s activated partial thromboplastin time (aPPT) level is 65 seconds. The client’s baseline before the initiation of therapy was 30 seconds. A nurse anticipates that which action is needed?

  1. Shutting off the heparin infusion
  2. Decreasing the rate of the heparin infusion
  3. Leaving the rate of the heparin infusion as is
  4. Increasing the rate of the heparin infusion

29.  A nurse is assisting to position the client for pericardiocentesis to treat cardiac tamponade. The nurse positions the client

  1. Lying on the left side with a pillow under the chest wall.
  2. Lying on the right side with a pillow under the head.
  3. Supine with the head of bed elevated at a 45- to 60-degree angle.
  4. Supine with slight Trendelenburg position.

30.  A male client who has been exercising in a gymnasium stops to measure his pulse and places his fingers over both carotid arteries simultaneously. A nurse exercising nearby cautions him to check the pulse on only one side primarily because

  1. It is unnecessary to use both hands.
  2. Feeling dual pulsations may lead to an incorrect measurement.
  3. The client could occlude the trachea.
  4. The heart rate and blood pressure could drop.

31.  A client is admitted to the hospital with a diagnosis of aortic regurgitation. The nurse understands that the failure of this valve to close completely allows blood to flow retrograde from the

  1. Left ventricle to left atrium.
  2. Aorta to left ventricle.
  3. Right ventricle to right atrium.
  4. Pulmonary artery to right ventricle.

32.  At 3 AM, the mother of a 3-year-old calls the emergency room nurse and reports the child has a temperature of 101.1°F (38.4°C), a runny nose, and a barky cough that "gets going and won't stop." The mother states that she just gave the child acetaminophen (Tylenol). Which of the following should the nurse recommend next?

  1. Sitting with the child in a steamy warm bathroom.
  2. Running a steam vaporizer near the child's bedside.
  3. Giving the child an over-the-counter decongestant.
  4. Administering aspirin in 2 hours.

33.  The client is brought into the emergency room in ventricular fibrillation. The advanced cardiac life support nurse prepares to defibrillate by placing conductive gel pads on which part of the chest?

  1. To the upper and lower half of the sternum
  2. To the right of the sternum just below the clavicle and left of the precordium
  3. To the right shoulder and in the back of the left shoulder
  4. Parallel between the umbilicus and the right nipple

34.  A nurse is evaluating the condition of a client after pericardiocentesis for cardiac tamponade. Which of the following observations would indicate that the procedure was unsuccessful?

  1. Rising central venous pressure
  2. Rising blood pressure
  3. Client expressions of relief
  4. Clearly audible heart sounds

35.  A 78-year-old woman is admitted to the hospital. Digoxin (Lanoxin), spironolactone (Aldactone), furosemide (Lasix), and cardiac monitoring are prescribed. The physician's order for the patient's first dose of digoxin reads, "digoxin 0.5 milligram PO now." Which of the following actions, if taken by the nurse, would be MOST appropriate?

  1. Do not administer the digoxin.
  2. Call the physician.
  3. Administer half the prescribed dose of digoxin.
  4. Administer the digoxin as ordered.

36.  A nurse is assessing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second. The overall heart rate is 64 beats per minute. The nurse assesses the cardiac rhythm as

  1. Normal sinus rhythm.
  2. Sinus bradycardia.
  3. Sick sinus syndrome.
  4. First-degree heart block.

37.  A nurse is instructing the post-cardiac surgery client about activity limitations for the first 6 weeks after hospital discharge. The nurse would include which of the following items in the instruction?

  1. Resume activities that involve straining as long as they do not cause pain.
  2. Drive as long as the lap and shoulder seat belts are worn.
  3. Lift objects that do not weigh more than 25 lb.
  4. Use the arms for balance, not weight support, when getting out of bed or a chair.

38.  When monitoring a client's central venous pressure (CVP), the nurse knows that a normal CVP: measurement is:

  1. 2 cm H20.
  2. 1 mm Hg.
  3. 10 mm Hg.
  4. 5 cm H20.

39.  A client with chronic obstructive pulmonary disease (COPD) and cor pulmonale is being prepared for discharge. The nurse should provide which instructions?

  1. "Weigh yourself daily and report a loss of 1 lb in 1 day."
  2. "Eat a high-sodium diet."
  3. "Weigh yourself daily and report a gain of 2 lb in 1 day."
  4. "Maintain bedrest."

40.  A child presents in the clinic with iron deficiency anemia. As the nurse, you would expect which of the following symptoms to be present in this patient?

  1. Abdominal pain and vomiting
  2. Poor posture and unclear speech
  3. Bradycardia and dyspnea
  4. Poor muscle tone and decreased activity

41.  When obtaining a health history from the mother of a 7-year-old child diagnosed with acute rheumatic fever, the nurse would focus questions to determine if the child was recently ill with which of the following?
  1. Measles.
  2. Mumps.
  3. Sore throat.
  4. Influenza virus.

42.  The most important nursing responsibility during a myringotomy procedure on an 18-month-old child is to:

  1. Collect the aspirated drainage in a culture tube
  2. Maintain the continuous flow of local anesthetic
  3. Have the mother stay and hold the child in her arms
  4. Keep the child restrained and completely immobilized

43.  A female client is at risk for developing disseminated intravascular coagulation. The nurse is reviewing the laboratory results and determines that the fibrinogen level is normal if which of the following is noted on the laboratory report?
  1. 180 mg/dL
  2. 400 mg/dL
  3. 480 mg/dL
  4. 500 mg/dL
44.  A 54-year-old woman comes to the emergency department complaining of chest pain on exertion. The pain subsides with rest. A myocardial infarction (MI) is ruled out and the client is diagnosed with unstable angina. The woman says, "I really thought I was having a heart attack. How can you tell the difference?" Which response by the nurse would provide the client with the most accurate information about the difference between the pain of angina and that of MI?

  1. "The pain associated with a heart attack is much more severe."
  2. "The pain associated with a heart attack radiates into the jaw and down the left arm."
  3. "It is impossible to differentiate anginal pain from that of a heart attack without an ECG."
  4. "The pain of angina is usually relieved by resting or lying down."

45.  A client with hypertension has been told to maintain a diet low in sodium. A nurse who is teaching this client about foods that are allowed would plan to include which food item in a list provided to the client?

  1. Tomato soup
  2. Summer squash
  3. Instant oatmeal
  4. Boiled shrimp

46.  A client has developed atrial fibrillation with a ventricular rate of 150 beats per minute. The nurse assesses the client for:

  1. Hypotension and dizziness.
  2. Nausea and vomiting.
  3. Hypertension and headache.
  4. Flat neck veins.

47.  Which of the following clinical manifestations would be most indicative of complete arterial obstruction in the lower extremities?
  1. Aching pain.
  2. Burning sensations.
  3. Numbness and tingling.
  4. Coldness.

48.  The nurse is documenting her care for a client with iron deficiency anemia. Which of the following nursing diagnoses is most appropriate?

  1. Impaired gas exchange
  2. Deficient fluid volume
  3. Ineffective airway clearance
  4. Ineffective breathing pattern

49.  A left atrial catheter is inserted into a client during cardiac surgery. The nurse is monitoring the left atrial pressure and documents that the pressure is normal if which of the following pressures was noted?
  1. 8 mm Hg
  2. 15 mm Hg
  3. 25 mm Hg
  4. 32 mm Hg
50.  A client is scheduled to undergo cardiac catheterization for the first time, and the nurse provides instructions to the client. Which client statement indicates a clear understanding of the instructions?

  1. “I will have to go to the operating room for this procedure.”
  2. “I will probably feel tired after the test from lying on a hard x-ray table for a few hours.”
  3. “It will really hurt when the catheter is first put in.”
  4. “I will receive general anesthesia for the procedure.”

51.  A nurse is caring for a client in the telemetry unit who is receiving an intravenous infusion of 1000 mL 5% dextrose with 40 mEq of potassium chloride. Which of the following if noted on the cardiac monitor would indicate the presence of hyperkalemia?

  1. Tall, peaked T waves.
  2. ST segment depression.
  3. Shortening of the QRS complex.
  4. Shortened PR interval.

52.  Which of the following methods would the nurse use to feed an infant after surgical repair of cleft lip?

  1. Gastric gavage.
  2. Intravenous fluids.
  3. Rubber-tipped medicine dropper.
  4. Bottle with a lamb's nipple.

53.  The nurse is preparing the client with heart failure to go home. The nurse should instruct the client to:

  1. Monitor urine output daily.
  2. Maintain bed rest for at least 1 week.
  3. Monitor daily potassium intake.
  4. Weigh daily.

54.  A client is at risk for pulmonary embolism and is on anticoagulant therapy with warfarin sodium (Coumadin). The client’s prothrombin time is 20 seconds, with a control of 11 seconds. The nurse assesses that this result is

  1. The same as the client’s own baseline level.
  2. Lower than the needed therapeutic level.
  3. Within the therapeutic range.
  4. Higher than the therapeutic range.

55.  The mother of a 15-month-old who is coughing and having trouble breathing telephones the clinic to ask advice because she suspects that her child has croup. Which of the following instructions would be most appropriate?

  1. Administer acetaminophen (Tylenol) every 4 hours.
  2. Take the child into the bathroom and run the hot water.
  3. Give over-the-counter cough syrup every 6 hours.
  4. Get the child to take as much fluid as possible.

56.  A client is experiencing an acute myocardial infarction (MI) and I.V. morphine sulfate is prescribed. Morphine sulfate is given because it:

  1. eliminates pain, reduces cardiac workload, and increases myocardial contractility.
  2. lowers resistance, reduces cardiac workload, and decreases myocardial oxygen demand.
  3. raises the blood pressure, lowers myocardial oxygen demand, and eliminates pain.
  4. increases venous return, lowers resistance, and reduces cardiac workload.

57.  The parents report that the child has a runny nose, fever, cough, and is irritable and constantly rubbing his ears. The nurse would expect to see a tympanic membrane that appears as which of the following?

  1. Bulging and red.
  2. Clear and inverted.
  3. Pearly gray.
  4. Scarred.

58.  In presenting a workshop on parameters of cardiac function, which conditions should the nurse list as those most likely to lead to a decrease in preload?

  1. Hemorrhage, sepsis, and anaphylaxis
  2. Myocardial infarction, fluid overload, and diuresis
  3. Fluid overload, sepsis, and vasodilation
  4. Third spacing, heart failure, and diuresis

59.  During a shock state, the renin-angiotensin-aldosterone system exerts which effect on renal function?

  1. Decreased urine output, increased reabsorption of sodium and water
  2. Decreased urine output, decreased reabsorption of sodium and water
  3. Increased urine output, increased reabsorption of sodium and water
  4. Increased urine output, decreased reabsorption of sodium and water

60.  A client is scheduled to undergo percutaneous transluminal coronary angioplasty (PTCA). Which statement by the nurse best explains the procedure to the client?

  1. "PTCA involves opening a blocked artery with an inflatable balloon located on the end of a catheter."
  2. "PTCA involves cutting away blockages with a special catheter."
  3. "PTCA involves passing a catheter through the coronary arteries to find blocked arteries."
  4. "PTCA involves inserting grafts to divert blood from blocked coronary arteries."

61.  The plan of care for a client with hypertension taking propranolol hydrochloride would include:

  1. Instructing the client to discontinue the drug if nausea occurs and to monitor blood pressure.
  2. Monitoring blood pressure every week and adjusting the medication dose accordingly.
  3. Measuring partial thromboplastin time weekly to evaluate blood clotting status.
  4. Instructing the client to notify the physician of irregular or slowed pulse rate.

62.  The nurse recognizes that the diagnosis of celiac disease can be confirmed when a jejunal biopsy reveals:

  1. Small areas of fatty plaques
  2. Atrophic changes in the mucosal wall
  3. Irregular areas of superficial ulcerations
  4. Diffuse degenerative fibrosis of the acini

63.  A client is admitted to the hospital with a diagnosis of myocardial infarction and is going to have an intravenous nitroglycerin infusion started. Noting that the client does not have an intraarterial monitoring line in place, the nurse obtains which of the following pieces of equipment for use at the bedside?

  1. Central venous pressure insertion tray
  2. Noninvasive blood pressure monitor
  3. Defibrillator
  4. Pulse oximeter

64.  Which of the following would lead the nurse to suspect that a neonate with an infection is developing septic shock?

  1. Axillary temperature is 99.8°F (37.7°C).
  2. Blood pressure is 45/25 mm Hg.
  3. Heart rate during sleep is 205 bpm.
  4. Respiratory rate while awake is 32 breaths/minute.

65.  When teaching a client with peripheral vascular disease about foot care, the nurse should include which instruction?

  1. Avoid using cornstarch on the feet.
  2. Avoid wearing canvas shoes.
  3. Avoid using a nail clipper to cut toenails.
  4. Avoid wearing cotton socks.

66.  The mother, concerned about her infant's surgery for inguinal hernia repair, asks the nurse if her infant would have been scheduled for surgery even if the hernia had been asymptomatic. Which of the following statements offers the best explanation why the surgical repair would be done at this time?

  1. An infant is better able to tolerate the physical stress of surgery than an older child is.
  2. The experience of surgery is less frightening for the younger child.
  3. Less danger and fewer complications result when surgery is an elective procedure.
  4. Doing surgery near the genital organs is preferred before a child becomes conscious of sexual identity.

67.  A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium (Coumadin) has a prothrombin time (PT) of 30 seconds. Based on the prothrombin time, a nurse anticipates which of the following orders?

  1. Holding the next dose of warfarin
  2. Administering the next dose of warfarin
  3. Increasing the next dose of warfarin
  4. Adding a dose of heparin

68.  A nurse is caring for a client with a diagnosis of myocardial infarction. The client is experiencing chest pain that is unrelieved by the administration of nitroglycerine. The nurse administers morphine sulfate to the client as prescribed by the physician. Following administration of the morphine sulfate, the nurse plans to monitor.

  1. Mental status
  2. Respirations and blood pressure.
  3. Apical pulse rate.
  4. Temperature and blood pressure.

69. A nurse is planning to teach a client with heart disease about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid. Which food item should the nurse plan to include in this list?

  1. Broccoli
  2. Oranges
  3. Cream cheese
  4. Broiled haddock

70.  A nurse is developing a plan of care for a client with varicose veins who developed skin breakdown as a result of the disorder and secondary infection. The nurse includes a priority in the plan of care to

  1. Keep the legs aligned with the heart.
  2. Position the client onto the side every shift.
  3. Clean the skin with alcohol every hour.
  4. Elevate the legs higher than the heart.

71.  A patient is being treated for congestive heart failure with a diuretic medication. Based on the nurse's knowledge of the goal of diuretic therapy for the patient with congestive heart failure, which of the following assessments BEST indicates that the patient's condition is improving?

  1. The patient's weight has remained stable since admission.
  2. The patient's systolic blood pressure has decreased.
  3. There are fewer rales heard when auscultating the patient's lungs.
  4. The patient's urinary output is increasing.

72.  A client with chronic atrial fibrillation is being started on quinidine sulfate (Quinidex Extentabs) as maintenance therapy for dysrhythmia suppression, and the nurse provides instructions to the client about the medication. Which statement by the client indicates a need for further instructions?

  1. “I will stop taking the prescribed anticoagulant after starting this medication.”
  2. “I will take the medication with food if my stomach becomes upset.”
  3. “I will avoid chewing the sustained-release tablets.”
  4. “I will take the dose at the same time each day.”

73.  A nurse checks the laboratory result for a serum digoxin level that was drawn for a client earlier in the day and notes that the result is 2.4 ng/mL. Which of the following is the most important action on the part of the nurse?

  1. Record the normal value on the client’s flowsheet.
  2. Administer the next dose of the medication as scheduled.
  3. Check the client’s last rate.
  4. Notify the physician.

74.  A home health nurse is visiting an older client whose family has gone out for the day. During the visit, the client experiences chest pain that is unrelieved by three nitroglycerin tablets given by the nurse and placed sublingually. Which action by the nurse would be most appropriate at this time?

  1. Notify a family member who is the next of kin.
  2. Inform the home care agency supervisor that the visit may be prolonged.
  3. Call for an ambulance to transport the client to the emergency room.
  4. Drive the client to the physician’s office.
  
75.  In the well-child clinic a nurse teaches a group of parents guidelines that will possibly prevent Reye's syndrome in their young children. The nurse tells the parents:

  1. "If your children's temperature reaches 101 degree F, begin sponge bathing with alcohol."
  2. "Ask your doctor about inoculating your children with a specific immunization serum."
  3. "Restrict your children's carbohydrate intake when they have the symptoms of a cold."
  4. "Use an antipyretic other than aspirin when your children have a respiratory infection."

76.  Which of the following should the nurse do first when a neonate with myelomeningocele experiences urine retention with overflow incontinence?

  1. Apply gentle pressure to the suprapubic area.
  2. Initiate an intermittent clean catheterization program.
  3. Insert an indwelling urinary catheter.
  4. Collect a urine specimen.

77.  When assessing a 6-month-old child with a large ventricular septal defect, the nurse notices that the child has gained 5 pounds in 1 month. The mother reports that the child has not been wetting many diapers in the last week, although the child is taking the prescribed amounts of formula. "I think it is because he seems to sweat so much." Auscultation of the lung fields reveals fine crackles in the bases. The child's digoxin level is 1 mg/mL. Which of the following nursing diagnoses would be most appropriate?

  1. Imbalanced Nutrition: More Than Body Requirements.
  2. Excess Fluid Volume.
  3. Risk for Injury.
  4. Urinary Retention.

78.  A 4-year-old child with hemophilia is brought to the pediatrician's office with spontaneous soft tissue bleeding of the right knee. Immediately on the child's arrival, the nurse would plan to:

  1. Administer aspirin for discomfort.
  2. Immobilize the knee in a dependent position.
  3. Elevate the right knee.
  4. Do a type and cross-match for platelets.

79.  After surgical repair of a cleft lip, the infant exhibits difficulty breathing. Which of the following measures would the nurse institute first?

  1. Raising the infant's head.
  2. Turning the infant onto the abdomen.
  3. Administering oxygen per mask.
  4. Exerting downward pressure on the infant's chin.


80.  When examining the laboratory work of a child with the diagnosis of rheumatic fever, the nurse would expect the findings to demonstrate:

  1. A negative C-reactive protein
  2. A positive antistreptolysin titer
  3. An elevated reticulocyte count
  4. A decreased erythrocyte sedimentation rate

81.  Which of the following information obtained during a health history would the nurse correlate as consistent with the diagnosis of failure to thrive in a 5-month-old infant?

  1. Fussiness during feedings.
  2. Fear of strangers.
  3. Quiet when being held.
  4. Need to be awakened for feedings.

82.  A nursing instructor asks a nursing student to describe the structure and function of the coronary arteries. Which of the following responses by the student indicates a need for further research of the anatomy and physiology related to the heart?

  1. “The coronary arteries branch from the aorta.”
  2. “The coronary arteries supply the heart muscle with blood.”
  3. “The left coronary artery provides blood for the left atrium and the left ventricle.”
  4. “The left coronary artery supplies the right atrium and right ventricle with blood.”

83.  A newborn is suspected of having patent ductus arteriosus. The nurse should recognize that the newborn is at risk for the development of:

  1. mitral valve prolapse.
  2. inflammation of the pericardium.
  3. pulmonary edema.
  4. bacterial endocarditis.

84.  A nurse notices frequent artifact on the electrocardiogram monitor for a client whose leads are connected by cable to a console at the bedside. The nurse examines the client to determine the cause. Which of the following items is unlikely to be responsible for the artifact?
  1. Frequent movement of the client
  2. Tightly secured cable connections
  3. Leads applied over hairy areas
  4. Leads applied to the limbs

85.  A nurse is preparing for the admission of a client with heart failure who is being sent directly to the hospital from the physician’s office. The nurse would plan on having which of the following medications readily available for use?
  1. Diltiazem (Cardizem)
  2. Digoxin (Lanoxin)
  3. Propranolol (Inderal)
  4. Metoprolol (Lopressor)

86.  When preparing to obtain a blood sample to screen the neonate for phenylketonuria (PKU), from which of the following areas would the nurse anticipate obtaining the sample?

  1. Heel.
  2. Radial artery.
  3. Scalp vein.
  4. Brachial artery.

87.  Nursing care of an infant with respiratory distress syndrome (RDS) should be directed toward:

  1. Maintaining the infant in a warm environment
  2. Turning the infant frequently to prevent apnea
  3. Keeping the infant in oxygen concentrations of 40%
  4. Stimulating deep breathing by tapping the infant's toes

88.  The nurse in the coronary care unit obtains a pulse rate of 116 bpm before administering digoxin to the client with heart failure. The appropriate action by the nurse is to:

  1. Evaluate the client's cardiac rhythm.
  2. Administer the digoxin.
  3. Withhold the digoxin and take the pulse again in 15 minutes.
  4. Obtain the client's respiratory rate.

89.  A client is admitted to the visiting nurse services for assessment and follow-up after being discharged from the hospital for new onset congestive heart failure. The nurse teaches the client about the dietary restrictions to follow. Which statement by the client indicates that further teaching is needed?

  1. “I’m going to have a ham and cheese sandwich and potato chips for lunch.”
  2. “I’m going to weigh myself daily to be sure I don’t gain too much fluid.”
  3. “I can have most fresh fruits and fresh vegetables.”
  4. “I’m not supposed to eat cold cuts.”

90.  Following coronary artery bypass grafting, a client begins having chest "fullness" and anxiety. The nurse suspects cardiac tamponade and prints a lead II electrocardiograph (ECG) strip for interpretation. In looking at the strip, the change in the QRS complex that would most support her suspicion is:

  1. narrowing complex.
  2. widening complex.
  3. amplitude increase.
  4. amplitude decrease.

91.  An ECG is performed before a client is to have a cardiac catheterization, and hypokalemia is suspected. To confirm the presence of hypokalemia, the nurse would expect the physician to order:

  1. Blood cultures x 3
  2. A complete blood count
  3. A serum electrolyte level
  4. An x-ray film of long bones

92.  A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often in the morning. On further assessment a nurse notes that the pain occurs in the absence of precipitating factors. This type of anginal pain is best described as:

  1. Stable angina.
  2. Unstable angina.
  3. Variant angina.
  4. Nonanginal pain.

93.  A 25-day-old infant is admitted to the hospital after 3 days of vomiting, and pyloric stenosis is diagnosed. The most important nursing assessment at the time of admission is the:

  1. Character, amount, and times when the baby vomited
  2. Time of last feeding, type of formula, and amount taken
  3. Presence of an olive-shaped mass in the lower abdomen
  4. Amount and color of last voiding, skin turgor, and respiratory status

94.  A client receiving total parenteral nutrition has a history of congestive heart failure. The physician has ordered furosemide (Lasix) 40 mg PO daily to prevent fluid overload. The nurse monitors which laboratory value to identify adverse effects from this medication?

  1. Glucose
  2. Sodium
  3. Potassium
  4. Magnesium

95.  A client complains of calf tenderness. On assessment the nurse notes a positive Homans’ sign. The nurse next assesses the client for:

  1. Coolness and pallor of the affected limb.
  2. Diminished distal peripheral pulses.
  3. Increased calf circumference.
  4. Bilateral edema.

96.  A nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but over 100. The nurse determines that the client is experiencing:

  1. Premature ventricular contractions.
  2. Ventricular tachycardia.
  3. Ventricular fibrillation.
  4. Sinus tachycardia.


97.  A nurse is viewing the cardiac monitor in a client’s room and notes that the client has just gone into ventricular tachycardia. The client is awake and alert and has good skin color. The nurse would prepare to do which of the following?

  1. Immediately defibrillate.
  2. Prepare for pacemaker insertion.
  3. Administer amiodarone (Cordarone) intravenously.
  4. Administer epinephrine (Adrenalin) intravenously.

98.  Which of the following nursing interventions is most important postoperatively for an infant who has received a ventriculoperitoneal shunt?

  1. Monitoring intake and output.
  2. Initiating oral feedings.
  3. Allowing the infant to rest undisturbed.
  4. Providing age-appropriate diversionary activities.
99.  A client has a nursing diagnosis of “activity intolerance related to underlying cardiovascular disease, as evidenced by exertional fatigue and increased blood pressure.” Which observation by the nurse best indicates client progress in meeting goals for this nursing diagnosis?

  1. The client chooses a healthful diet that meets caloric needs.
  2. The client sleeps without awakening throughout the night.
  3. The client verbalizes the benefits of increasing activity.
  4. The client ambulates 10 feet farther each day.

100.  The parents of a neonate with a cleft lip are shocked when they see their child for the first time. Which of the following nursing actions would the nurse include in the neonate's plan of care to help the parents accept their infant's anomaly?

  1. Encouraging the parents to visit more frequently.
  2. Reassuring them that surgery will correct the defect.
  3. Showing them pictures of babies before and after corrective surgery.
  4. Allowing them to complete their grieving process before seeing the infant again
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