Practice Test 2 - QUESTIONS

1.       An 8-year-old child is sent home by the school nurse with pediculosis. The child's father speaks with the nurse and is obviously upset and embarrassed. Which of the following statements by the mother would indicate to the nurse that he understands how his child got pediculosis?

A.    "I brush her hair twice a day."

B.    "Could this result from sharing batting helmets at T-ball practice?"

C.   "I make sure she shampoos her hair daily."

D.   "We always use a dandruff-control shampoo."

2.       The nurse is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of performing the examination is to discover:

A.    cancerous lumps.

B.    areas of thickness or fullness.

C.   changes from previous self-examinations.

D.   fibrocystic masses.

3.       A client has had a cerebrovascular accident (CVA). Because the CVA affected the left side of the client's brain, the nurse should anticipate that the client would most likely experience:

A.    Expressive aphasia.

B.    Dyslexia.

C.   Apraxia.

D.   Agnosia.

4.       The nurse inspects a client's back and notices small hemorrhagic spots. The nurse documents that the client has:

A.    extravasation.

B.    osteomalacia.

C.   petechiae.

D.   uremia.

5.       Which of the following reasons, given by a mother who permits her preschool-aged child to sleep in the same bed (co-sleeping) as the parents, requires further investigation by the nurse?

A.    "I am too tired to get up at night to check on the baby in the other room."

B.    "This promotes bonding between us and our child."

C.   "I slept with my parents when I was a small child."

D.   "I can be certain my husband is not being inappropriate."

6.       A thallium scan is performed on a client with a history of chest pain to:

A.    Monitor action of the heart valves

B.    Determine myocardial muscle viability

C.   Visualize ventricular systole and diastole

D.   Determine adequacy of electrical conductivity

7.       An infant experiencing severe diarrhea for the past 2 days is brought to the emergency department by his parents. Which of the following laboratory test results would lead the nurse to suspect hypertonic dehydration?

A.    Elevated serum sodium levels

B.    Normal serum chloride levels

C.   Normal serum potassium levels

D.   Decreased serum chloride levels

8.       Which of the following actions is appropriate when performing a physical assessment on a 2-year-old?

A.    Begin with the least intrusive procedure

B.    Carefully explain all procedures at this time

C.   Proceed in a head to toe manner

D.   Ask the parent to leave the room

9.       A client with shock brought on by hemorrhage has a temperature of 97.6

A.    "Monitor urine output every hour."

B.    "Infuse I.V. fluids at 83 ml/hr"

C.   "Administer oxygen by nasal cannula at 3 L/minute"

D.   "Draw samples for hemoglobin and hematocrit every 6 hours."

10.   The nurse is revising a client's plan of care. During which step of the nursing process does such revision take place?

A.    Assessment

B.    Planning

C.   Implementation

D.   Evaluation

11.   After suctioning a tracheostomy tube, the nurse assesses the client to determine the effectiveness of the suctioning. Which findings indicate that the airway is now patent?

A.    A respiratory rate of 24 breaths/minute with accessory muscle use

B.    Effective breathing at a rate of 16 breaths/minute through the established airway

C.   Increased pulse rate, rapid respirations, and cyanosis of the skin and nail beds

D.   Restlessness, pallor, increased pulse and respiratory rates, and bubbling breath sounds

12.   A 2-year-old child is brought to the emergency department with a history of upper airway infection that has worsened over the last 2 days. The nurse suspects the child has croup. Signs of croup include a hoarse voice, inspiratory stridor, and:

A.    a barking cough.

B.    a high fever.

C.   sudden onset.

D.   dysphagia.

13.   The most important information for the nurse to have when planning care for the client with diabetes is the client's?

A.    Family medical history

B.    Blood glucose history

C.   24-hour dietary history

D.   Medical history

14.   Which of the following is the most common method used to prevent bronchopulmonary dysplasia (BPD) in very low birth weight infants?

A.    Using the lowest peak inspiratory pressure and O2 level necessary to maintain adequate oxygenation.

B.    Suctioning the neonate's hypopharynx vigorously before the delivery of the shoulders.

C.   Preventing premature delivery, especially in early delivery and cesarean sections.

D.   Administering exogenous surfactant shortly after a premature baby is born.

15.   Two middle-aged sisters have been diagnosed with Huntington's disease. The children of these clients want to know what their chances are of developing this genetic disorder. The nurse's best response would be:

A.    "Only women become symptomatic."

B.    "This disorder is an autosomal dominant disorder, so each child has a 50% chance of inheriting it."

C.   "This disorder is an autosomal recessive disorder, so each child has a 25% chance of inheriting it."

D.   "Women are symptomatic and men are carriers of this disorder."

16.   Lochia normally progresses in which pattern?

A.    Rubra, serosa, alba

B.    Serosa, rubra, alba

C.   Serosa, alba, rubra

D.   Rubra, alba, serosa

17.   When administering an IM injection to a 9-month-old, which of the following measures would be most appropriate?

A.    Enlisting the help of another nurse to maintain the infant's position

B.    Waiting until the infant is asleep to administer the injection

C.   Administering the injection into the dorsogluteal site

D.   Massaging the site after giving the injection slowly

18.   Which of the following would be the nurse's least concern for a child requiring prolonged immobilization?

A.    Decreased catabolic activity related to muscle atrophy

B.    Hypercalcemia due to bone demineralization

C.   Dependent edema related to decreased venous return

D.   Decreased movement of secretions from the tracheobronchial tree

19.   The nurse assesses the client's urinary stoma regularly for edema. Which of the following signs and symptoms might indicate excessive stomal edema?

A.    Elevated temperature.

B.    Urine dribbling from the stoma.

C.   Complaints of discomfort around the stoma.

D.   Urine output below 30 mL/hour.

20.   Before a wellness checkup in the pediatrician's office, an 8-month-old infant is sitting contentedly on the mother's lap, chewing a toy. When preparing to examine this infant, which of the following steps should the nurse do first?

A.    Obtain body weight.

B.    Auscultate heart and breath sounds.

C.   Check pupillary response.

D.   Measure the head circumference.

21.   A client with achalasia is to have bougienage to dilate the lower esophagus and cardiac sphincter. Following the procedure the nurse should assess the client for esophageal perforation, which is indicated by:

A.    Faintness and feelings of fullness

B.    Diaphoresis and cardiac palpitations

C.   Increased heart rate and abdominal pain

D.   Increased blood pressure and urinary output

22.   Following a tonic-clonic seizure, a client has snoring respirations. The physician orders a nasopharyngeal airway inserted to protect the client's airway. The nurse is inserting the airway correctly when she:

A.    depresses the tongue as the airway is inserted.

B.    lubricates the airway with petroleum jelly.

C.   inserts the airway with the tip upward.

D.   gently pushes the airway along the floor of the nostril.

23.   A preschooler is admitted to the hospital the day before scheduled surgery. This is the child's first hospitalization. Which action will best help reduce the child's anxiety about the upcoming surgery?

A.    Begin preoperative teaching immediately.

B.    Describe preoperative and postoperative procedures in detail.

C.   Give the child dolls and medical equipment to play out the experience.

D.   Explain that the child will be put to sleep during surgery and won't feel anything.

24.   When the nurse is teaching a group of parents about common childhood problems, a parent asks, "Why are children more likely to develop ear infections than adults are?" The nurse bases the response to this question on the understanding that the key anatomic difference between adults and children is due to which of the following structures?

A.    Nasopharynx.

B.    Eustachian tubes.

C.   Ear canals.

D.   Tympanic membranes.

25.   Which laboratory finding supports a diagnosis of pyelonephritis?

A.    Myoglobinuria

B.    Ketonuria

C.   Pyuria

D.   Low white blood cell (WBC) count

26.   The nurse notes that the client's urinary appliance contains pale yellow urine with large amounts of mucus. How would the nurse best interpret these data?

A.    The client is developing an infection of the urinary tract.

B.    The mucus is caused by elevated levels of glucose in the urine.

C.   These findings are normal for a client with an ileal conduit.

D.   There is irritation of the stoma.

27.   When reviewing the client's chart, the nurse should pay close attention to the results of which pulmonary funtion test?

A.    Residual volume

B.    Total lung capacity

C.   FEV1/FVC ratio

D.   Functional residual capacity

28.   Which assessment finding would the nurse identify as abnormal for a 4-month-old?

A.    The abdominal wall is rising with inspiration.

B.    The respiratory rate is between 30 and 35 breaths/minute

C.   The infant's skin is mottled during examination.

D.   The spaces between the ribs (intercostal) are delineated during inspiration.

29.   The nurse assesses a client who is complaining of frequent episodes of epistaxis. The nurse knows the client has:

A.    an enlarged spleen.

B.    a tendency to bruise easily.

C.   nosebleeds.

D.   seizures.

30.   The nurse is caring for a bulimic client and an anorectic client. What cognitive characteristics would be similar for both of these clients?

A.    Perfectionism, preoccupation with food

B.    Relaxed personality, but preoccupied with food

C.   No similarities

D.   Preoccupation with exercise

31.   When performing a physical examination on an infant, the nurse notes abnormally low-set ears. This finding is associated with:

A.    otogenous tetanus.

B.    tracheoesophageal fistula.

C.   congenital heart defects.

D.   renal anomalies.

32.   A client is receiving 125 ml/hour of continuous I.V. fluid therapy. The nurse examines the venipuncture site and finds it red and swollen. Which of the following interventions would the nurse perform first?

A.    Slow the infusion to 10 ml/hour.

B.    Discontinue the infusion.

C.   Place cold towels on the site.

D.   Call the physician.

33.   When teaching colostomy care, it is especially important for the nurse to teach the client to care for the skin around the stoma by:

A.    Avoiding the use of soap or irritating agents

B.    Pouring saline over the stoma and rubbing to remove hardened feces

C.   Rinsing the area with hydrogen peroxide and applying fresh gauze bandages

D.   Washing the area gently with soap and water and applying a protective ointment

34.   A nurse finds a 3-year-old boy simulating intercourse with some dolls. The nurse should recognize this as which of the following?

A.    Normal curiosity during play

B.    A sign of possible sexual abuse

C.   A symptom of developmental delay

D.   The child's inexperience with doll play.

35.   Which of the following interventions would be most appropriate for the nurse to recommend to a client to decrease discomfort from hemorrhoids?

A.    Decrease fiber in the diet.

B.    Take laxatives to promote bowel movements.

C.   Use warm sitz baths.

D.   Decrease physical activity.

36.   When assessing a client with chest pain, the nurse obtains a thorough history. Which statement by the client is most suggestive of angina pectoris?

A.    "The pain lasted for about 45 minutes."

B.    "The pain resolved after I ate a sandwich."

C.   "The pain worsened when I took a deep breath."

D.   "The pain occurred while I was mowing the lawn."

37.   A client is scheduled for oral cholecystography. Which one of the following actions would the nurse plan to implement before the test?

A.    Have the client drink 1000 mL of water.

B.    Ask the client about possible allergies to iodine or shellfish.

C.   Administer an intravenous contrast agent the evening before the test.

D.   Administer tap-water enemas until clear.

38.   During a routine physical examination, a client's chest x-ray film reveals a lesion in the right upper lobe. When the nurse obtains a history from the client, the information that supports the physician's tentative diagnosis of pulmonary tuberculosis is:

A.    Frothy sputum and fever

B.    Dry cough and pulmonary congestion

C.   Night sweats and blood-tinged sputum

D.   Productive cough and engorged neck veins

39.   A client develops chronic pancreatitis. What would be the appropriate home diet for a client with chronic pancreatitis?

A.    A low-protein, high-fiber diet distributed over four to five moderate-sized meals daily.

B.    A low-fat, bland diet distributed over five to six small meals daily.

C.   A high-calcium, soft diet distributed over three meals and an evening snack daily.

D.   A diabetic exchange diet distributed over three meals and two snacks daily.

40.   A test that should be included in the yearly physical examination of men during the late middle and older adult years is:

A.    PSA

B.    ELISA

C.   Western blot

D.   Serum triglycerides

ETHICAL AND LEGAL ISSUES

41.   When caring for a patient in restraints, on what area of the bed should the restraints be anchored?

A.    The side rails

B.    The mattress hook

C.   The footboard

D.   The bed frame

42.   A patient who is a Jehovah's Witness is scheduled to have a bowel resection for colon cancer. When planning care for the patient, the nurse should be aware that

A.    the resected colon and surrounding tissue will be officially buried.

B.    surgery must be delayed until the curandero visits.

C.   Holy Communion should be given on the day of surgery.

D.   the patient will most likely refuse any blood transfusion.

43.   A nurse accidentally administers 40 mg of propranolol (Inderal) to a client instead of 10 mg. Although the client exhibits no adverse reactions to the larger dose, the nurse should:

A.    call the facility's attorney.

B.    inform the client's family.

C.   complete an incident report.

D.   do nothing because the client's condition is stable.

44.   Which of the following rights does a client lose by being admitted involuntarily to a psychiatric hospital? The right to:

A.    Send and receive mail.

B.    Vote in a national election.

C.   Make a will or legally binding contract.

D.   Sign out of the hospital against medical advice.

45.   A patient who is to undergo surgery will be signing an informed consent. The nurse's main responsibility when informed consent is obtained is to

A.    assure that the patient has not received any sedation two to three hours prior to signing the consent form.

B.    validate that the patient understands the procedure or the treatment.

C.   complete all blank spaces in front of the patient before witnessing.

D.   explain the procedure and any risk factors to the patient thoroughly.

46.   Two nurses are discussing a client's condition in the elevator. The employer of the mentioned client overhears the conversation and fires the client. The nurses may be liable for which of the following accusations?

A.    Assault

B.    Battery

C.   Neglect

D.   Breach of confidentiality

47.   Which of the following questions would be essential in a cultural assessment of a patient?

A.    How many times have you been married?

B.    At what times do you take your medications?

C.   Do you have any siblings?

D.   Are there foods that you cannot eat together?

48.   The nurse cares for a 45-year-old man scheduled to have a transurethral prostatectomy (TURP) for treatment of benign prostatic hypertrophy (BPH). The physician orders hydralazine 25 mg IM on call before surgery. The nurse administers hydroxyzine to the patient instead of hydralazine. Which of the following statements BEST reflects how the nurse should document this in the patient's chart?

A.    "Hydralazine 25 mg ordered; hydroxyzine 25 mg given; physician notified; blood pressure 130/84; pulse 86; respiration 12."

B.    "Hydroxyzine 25 mg given; hydralazine 25 mg ordered; physician notified; vital signs stable."

C.   "Hydroxyzine 25 mg mistakenly given; hydralazine 25 mg ordered."

D.   "Hydroxyzine 25 mg given; incident report completed."

49.   When the rights of a client on a mental health unit are suspended, the nurse has the specific responsibility to:

A.    Inform the client's family or guardian

B.    Carefully monitor all pharmacologic intervention

C.   Complete a rights denial form and forward it to the administrative officer

D.   Document the client's behavior and the reason why specific rights were denied

50.   A visitor from a room adjacent to a client asks the nurse what disease the client has. The nurse responds, "I will not discuss any client's illness with you. Are you concerned about it?" This response is based on the nurse's knowledge that to discuss a client's condition with someone not directly involved with that client is an example of:

A.    Libel

B.    Slander

C.   Negligence

D.   Invasion of privacy

51.   The nurse accompanies a physician to the room of a newly admitted elderly patient with dementia. Upon examination, the patient has an extremely painful, reddened and enlarged abscess on the right elbow. The physician proceeds to incise the abscess area without anesthetic, and the patient cries out loudly in pain. The most appropriate immediate nursing action is to

A.    provide pain medication after the procedure.

B.    assist in restraining the patient during the procedure.

C.   request that the physician stop the procedure until an anesthetic can be administered.

D.   attempt to distract the patient during the procedure.

52.   A patient with a terminal illness is rapidly deteriorating but remains alert, oriented and verbally responsive. He states, "I am tired of being ill. I wish it could end today." The nurse should record this information using which of the following statements?

A.    Patient states, "I am tired of being ill. I wish it could end today."

B.    Patient seems depressed about his illness.

C.   Patient reports being sick all the time and wishes to die.

D.   Patient seems worried about something and states he wants to end it all.

53.   The nurse works with a colleague who consistently fails to use standard precautions or wear gloves when caring for clients. The nurse calls the colleague's attention to these oversights. The colleague tells the nurse that standard precautions and gloves are unnecessary unless the client is known to have tested positive for the human immunodeficiency virus. Which is the most appropriate action for the nurse to take?

A.    Ignore it because it isn't directly the nurse's problem.

B.    Document the problem in writing for the manager.

C.   Talk to other staff members to ascertain their practices.

D.   Instruct the clients to remind this colleague to wear gloves.

54.   The nurse is concerned about another nurse's relationship with the members of a family and their ill preschooler. Which of the following behaviors would be most worrisome and should be brought to the attention of the nurse-manager?

A.    The nurse keeps communication channels open among herself, the family, physicians, and other health care providers.

B.    The nurse attempts to influence the family's decisions by presenting her own thoughts and opinions.

C.   The nurse works with the family members to find ways to decrease their dependence on health care providers.

D.   The nurse has developed teaching skills to instruct the family members so they can accomplish tasks independently.

55.   While orienting a new nurse to the unit, the charge nurse stresses the importance of accurate documentation. The primary reason for a nurse to document care accurately is to

A.    demonstrate responsibility and accountability.

B.    prevent any legal action against the healthcare facility and its staff.

C.   facilitate insurance reimbursement.

D.   be in compliance with individual regulatory agencies.

56.   A nurse is assigned to all of the following patients. Which patient should the nurse assess first?

A.    The patient requesting medication for chest pain

B.    The patient who has an intravenous medication due in 30 minutes

C.   The patient who has a temperature of 101°F

D.   The patient who is scheduled to go to surgery within the hour

57.   The physician writes a "DNR" order on a patient's chart. The nurse should understand that DNR stands for

A.    dopamine and nitroglycerin recombination.

B.    diagnostic neurological radiation.

C.   do not resuscitate.

D.   dependent nitrogen re-uptake.

58.   A nurse works on a medical-surgical unit where nurses work on 12-client pods. Each pod is staffed by two registered nurses. When one of the nurses leaves the unit, the remaining nurse cares for all 12 clients. If she needs help, she can call the agency's in-house resource nurse. One evening when a coworker left the unit, the remaining nurse, who was making rounds on the departed nurse's clients, found medications left at bedsides and a client with a blood-draw tourniquet remaining on his arm. In addressing the problems, the nurse should:

A.    inform the nurse-supervisor right away.

B.    correct the problems and submit a written report.

C.   speak to the coworker when she returns to the unit.

D.   ask for a meeting with the coworker and a manager.

59.   Touching other people without their permission, reading someone else's mail, and using personal possessions without asking permission are all examples of:

A.    antisocial behavior.

B.    manipulation.

C.   poor boundaries.

D.   passive-aggressive behavior.

60.   A 22-year-old male client with AIDS signs a do not resuscitate (DNR) order when he is admitted to the hospital. When respiratory arrest occurs 3 weeks later the client is not resuscitated. A true statement about the legal aspects of a DNR order would be:

A.    Age is an important factor in the decision not to resuscitate

B.    The decision not to resuscitate resides with the client's physician

C.   The status of the DNR order is contingent on the policies of the institution

D.   Once the order has been signed, it remains in force for the entire hospitalization

61.   A client with mitral valve prolapse is advised to have elective mitral valve replacement. Because the client is a Jehovah's Witness, she declares in her advance directive that no blood products are to be administered. As a result, the consulting cardiac surgeon refuses to care for the client. It would be most appropriate for the nurse caring for the client to:

A.    realize the surgeon has the right to refuse to care for the client.

B.    advise the surgeon to arrange for an alternate cardiac surgeon.

C.   tell the client that she can donate her own blood for the procedure.

D.   inform the client that her decision could shorten her life.

62.   The nursing care coordinator in the surgical intensive care unit notes that a number of clients do not seem to be responding to meperidine (Demerol) that has been administered for pain. Later that evening the coordinator finds a staff nurse in the nurses' lounge dozing. On being awakened the staff nurse appears somewhat uncoordinated and drugged with slurred speech. The coordinator should:

A.    Ask the other staff members whether they have noticed anything unusual

B.    Tell the staff nurse that everyone now knows who has been stealing the Demerol

C.   Call the nursing director and have the director present before confronting the staff nurse

D.   Arrange to secretly observe the staff nurse the next time the staff nurse administers Demerol

63.   An abused child is admitted to the hospital, and the nurse is aware that a court appearance may be necessary. To plan for this eventuality, which of the following would be the priority?

A.    Remembering the parents' and child's behavior when the child was admitted.

B.    Documenting physical findings and behaviors observed during the child's admission.

C.   Formulating subjective opinions about the cause of any injuries.

D.   Preparing answers to questions that may be asked by the attorneys.

64.   A client in a behavioral-health facility receives a 30-minute psychotherapy session, and the provider uses a current procedure terminology (CPT) code that bills for a 50-minute session. Under the False Claims Act, such illegal behavior is known as:

A.    unbundling.

B.    overbilling.

C.   upcoding.

D.   misrepresentation.

65.   The employer of a client on the psychiatric unit calls the nursing station inquiring about the client's progress. The nurse doesn't know if consent has been given by the client to allow the staff to give information out to callers on the phone. Which of the following would be the nurse's best response?

A.    "I'm not permitted to discuss her progress."

B.    "I'll give you the name and telephone number of her physician."

C.   "I'll have her call you."

D.   "I can't confirm whether your employee is a client here."

66.   The nurse caring for a patient from a culture not her own can increase her cultural sensitivity by

A.    being aware of the patient's social standards.

B.    paying attention to environmental cues.

C.   identifying her personal reaction to the patient.

D.   talking with other staff who have interacted with the patient.

67.   The physician places a client with an infected surgical incision on strict isolation. After being taught about isolation, the client is seen sneaking out of the room to make telephone calls on the public phone. The most effective nursing intervention would be to:

A.    Ensure regular visits by staff members

B.    Explore what isolation means to the client

C.   Report the situation to the infection control nurse

D.   Reteach the entire isolation procedure to the client

68.   Which of the following conditions is most commonly associated with ethical and moral issues regarding life support withdrawal and organ donation?

A.    Anencephaly

B.    Microcephaly

C.   Encephalocele

D.   Meningocele

69.   A new practical nurse on the unit informs the nurse that an error was made. The patient suffered no adverse effects. The practical nurse asks the nurse if a medication error form should be completed even though "no harm was done." Which of the following statements, if made by the nurse, MOST accurately answers the question?

A.    "Since no harm was done, you do not have to complete a medication error form."

B.    "You must complete a medication error form whenever a medication error is made."

C.   "Call the doctor to determine whether a medication error form should be completed."

D.   "The type of medication error that you made will determine whether a medication error form should be completed."

70.   The nurse at a substance abuse center answers the phone. A probation officer asks if a client is in treatment. The nurse responds, "No, the client you're looking for isn't here." Which of the following statements best describes the nurse's response?

A.    Correct because she didn't give out information about the client

B.    A violation of confidentiality because she informed the officer that the client wasn't there

C.   A breech of the principle of veracity because the nurse is misleading the officer

D.   Illegal because she's withholding information from law enforcement agents

71.   As an adolescent is receiving care, he's inadvertently injured with a warm compress. The nurse completes an incident report based on the knowledge that identification of which of the following is not a goal of the report?

A.    Staff involved so they're reprimanded for their actions

B.    Learning needs of staff to prevent recurrence of incidents

C.   Patterns of client care problems

D.   Facts surrounding each incident

72.   Which barrier should the nurse avoid to manage her time effectively?

A.    Setting limits

B.    Procrastination

C.   Realistic personal expectations

D.   Practical planning

73.   A 23-year-old woman comes to the emergency room stating that she had been raped. Which of the following statements BEST describes the nurse's responsibility concerning written consent?

A.    The nurse should explain the procedure to the patient and ask her to sign the consent form.

B.    The nurse should verify that the consent form has been signed by the patient and that it is attached to her chart.

C.   The nurse should tell the physician that the patient agrees to have the examination.

D.   The nurse should verify that the patient or a family member has signed the consent form.

74.   Which of the following findings would a nurse suspect when she notices a colleague taking frequent breaks, working extra shifts and having inaccurate drug counts?

A.    The colleague is a victim of domestic violence.

B.    The colleague is abusing a substance.

C.   The colleague has a personality disorder.

D.   The colleague is trying to get out of work.

75.   The nurse is assigned to care for an elderly client who is confused and repeatedly attempts to climb out of bed. The nurse asks the client to lie quietly and leaves her unsupervised to take a quick break. While the nurse is away, the client falls out of bed. She sustains no injuries from the fall. Initially, the nurse should treat this occurrence as:

A.    a quality improvement issue.

B.    an ethical dilemma.

C.   an informed consent problem.

D.   a risk management incident.

76.   A 92-year-old client with prostate cancer and multiple metastases is in respiratory distress and is admitted to a medical unit from a skilled nursing facility. His advance directive states that he doesn't want to be placed on a ventilator or receive cardiopulmonary resuscitation. Based on the client's advance directive, the nursing plan of care should include which intervention?

A.    Check on the client once per shift.

B.    Provide mouth and skin care only if the family requests it.

C.   Turn the client only if he's uncomfortable.

D.   Provide emotional support and pain relief.

77.   A 49-year-old client with acute respiratory distress watches everything the staff does and demands full explanations for all procedures and medications. Which of the following actions would best indicate that the client has achieved an increased level of psychological comfort?

A.    Making decreased eye contact

B.    Asking to see family members

C.   Joking about the present condition

D.   Sleeping undisturbed for 3 hours

78.   A patient who is admitted to the hospital gives the nurse an advance directive. The nurse should understand that an advance directive is

A.    a written statement by the patient that defines acceptable care if the patient becomes incapacitated.

B.    the name of the person designated by the patient to make health-related decisions should the patient become incapacitated.

C.   a statement identifying the patient as an organ donor.

D.   a written statement authorizing a particular surgical procedure.

79.   An elderly patient who is being assessed for postoperative pain, tells the nurse "I don't want to bother you. I'll be okay." Which of the following indicators should the nurse initially use to assess this patient for pain?

A.    Statement of discomfort

B.    Nonverbal indicators of pain

C.   Changes in vital sign parameters

D.   Frequency of pain medication requests

80.   A 16-year-old, her 1-month-old baby, and the baby's grandmother come to the emergency room saying that the infant accidentally fell down the stairs. Legally, consent for the baby's medical care:

A.    Should be obtained from the grandmother, who must sign the consent

B.    Must be decided by family court because the baby's mother is a minor

C.   Is not necessary because this is an emergency and no consent is needed

D.   Is the responsibility of the baby's mother, and she should sign the consent

FLUID AND ELECTROLYTES

IV THERAPY

81.   A mist tent contains a nebulizer that creates a cool, moist environment for a child with an upper respiratory tract infection. The cool humidity helps the child breathe by:

A.    decreasing respiratory tract edema.

B.    preventing anxiety.

C.   drying secretions.

D.   increasing fluid intake.

82.   A bone mineral analysis reveals that a patient who is postmenopausal has severe osteoporosis. Which of the following instructions should the nurse give to the patient's family to ensure a safe environment for the patient?

A.    "Disinfect the bathroom weekly."

B.    "Carpet floor surfaces."

C.   "Install handrails on stairways."

D.   "Keep the lights dim."

83.   Based on multiple referrals, the nurse determines that childhood injuries are increasing in the community in which she practices. The first step the nurse would take in developing an educational program is:

A.    assessing for a decrease in referrals following a pediatric safety class.

B.    assessing the strengths and needs of the community while identifying barriers to learning.

C.   choosing a health promotion or health belief model as a framework.

D.   developing and implementing a specific plan to decrease childhood injuries.

84.   Which of the following activities would the nurse likely choose to implement in response to a nursing diagnosis of Activity Intolerance related to lack of energy conservation?

A.    Encourage the client to perform all tasks early in the day.

B.    Encourage the client to alternate periods of rest and activity throughout the day.

C.   Administer narcotics to promote pain relief and rest.

D.   Instruct the client to not perform daily hygienic care until activity tolerance improves.

85.   A client has a diagnosis of borderline personality disorder. She has attached herself to one nurse and refuses to speak with other staff members. She tells the nurse that the other nurses are mean, withhold her medication, and mistreat her. The staff is discussing this problem at their weekly conference. Which intervention would be most appropriate for the nursing staff to implement?

A.    Provide an unstructured environment for the client.

B.    Rotate the nurses who are assigned to the client.

C.   Ignore the client's behaviors.

D.   Bend unit rules to meet the client's needs.

86.   A client's chest tube accidentally disconnects from the drainage tube when she turns onto her side. Which of the following actions should the nurse take first?

A.    Notify the physician.

B.    Clamp the chest tube.

C.   Raise the level of the drainage system.

D.   Reconnect the tube.

87.   For a client with COPD who has trouble raising respiratory secretions, which of the following nursing measures would help reduce the tenacity of secretions?

A.    Ensuring that the client's diet is low in salt.

B.    Ensuring that the client's oxygen therapy is continuous.

C.   Helping the client maintain a high fluid intake.

D.   Keeping the client in a semi-sitting position as much as possible.

88.   A client, now 37 weeks pregnant, calls the clinic because she's concerned about being short of breath and is unable to sleep unless she places three pillows under her head. After listening to her concerns, the nurse should take which action?

A.    Make an appointment because the client needs to be evaluated.

B.    Explain that these are expected problems for the latter stages of pregnancy.

C.   Arrange for the client to be admitted to the birth center for delivery.

D.   Tell the client to go to the hospital; she may be experiencing signs of heart failure from a 45% to 50% increase in blood volume.

89.   A nurse works on a medical-surgical unit where nurses work on 12-client pods. Each pod is staffed by two registered nurses. When one of the nurses leaves the unit, the remaining nurse cares for all 12 clients. If she needs help, she can call the agency's in-house resource nurse. One evening when a coworker left the unit, the remaining nurse, who was making rounds on the departed nurse's clients, found medications left at bedsides and a client with a blood-draw tourniquet remaining on his arm. In addressing the problems, the nurse should:

A.    inform the nurse-supervisor right away.

B.    correct the problems and submit a written report.

C.   speak to the coworker when she returns to the unit.

D.   ask for a meeting with the coworker and a manager.

90.   The nurse is caring for a client with a history of falls. The first priority when caring for a client at risk for falls is:

A.    placing the call light for easy access.

B.    keeping the bed at the lowest position possible.

C.   instructing the client not to get out of bed without assistance.

D.   keeping the bedpan available so that the client doesn't have to get out of bed.

91.   Which of the following nursing interventions should have the highest priority during the first hour after the admission of a client with cholecystitis who is experiencing pain, nausea, and vomiting?

A.    Administering pain medication.

B.    Completing the admission history.

C.   Maintaining hydration.

D.   Teaching about planned diagnostic tests.

LEADERSHIP AND MANAGEMENT ISSUES

92.   Under the Good Samaritan Act, a nurse may be held liable for patient abandonment at the scene of an emergency in which of the following cases?

A.    The nurse does not stop to provide assistance.

B.    The nurse begins assistance and then abruptly stops.

C.   The nurse does not initiate care.

D.   The nurse does not perform under the direct order of a physician.

93.   The nurse receives an assignment to provide care to 15 clients. Two of them have had kidney transplantation surgery within the last 36 hours. The nurse feels overwhelmed with the number of clients. In addition, the nurse has never cared for a client who has undergone recent transplantation surgery. What is the appropriate action for the nurse to take?

A.    Speak to the manager and document in writing all concerns related to the assignment.

B.    Refuse the assignment.

C.   Ignore the assignment and leave the unit.

D.   Trade assignments with another nurse.

94.   The nurse accompanies a physician to the room of a newly admitted elderly patient with dementia. Upon examination, the patient has an extremely painful, reddened and enlarged abscess on the right elbow. The physician proceeds to incise the abscess area without anesthetic, and the patient cries out loudly in pain. The most appropriate immediate nursing action is to

A.    provide pain medication after the procedure.

B.    assist in restraining the patient during the procedure.

C.   request that the physician stop the procedure until an anesthetic can be administered.

D.   attempt to distract the patient during the procedure.

95.   In planning a presentation that advocates a decrease in the client-to-nurse ratio from 8:1 to 6:1, a nurse should emphasize its effect on:

A.    institutional resources.

B.    standards of practice.

C.   client-care quality.

D.   nursing recruitment.

96.   Which document addresses the client's rights to information, informed consent, and treatment refusal?

A.    Standards of Nursing Practice

B.    Patient's Bill of Rights

C.   Nurse Practice Act

D.   Code for Nurses

97.   Which of the following explanations would the nurse give to a patient regarding the role of the case manager?

A.    The case manager makes daily patient assignments for staff.

B.    The case manager coordinates both inpatient hospitalization and home care.

C.   The case manager negotiates insurance benefits with the hospital.

D.   The case manager decides what treatments are essential.

98.   A physician writes the following order for a client: "Prednisone 5 mg P.O. daily for 3 days." The nurse who transcribes the order onto the medication administration record (MAR) neglects to place the limitation of 3 days on the prescription. On the 4th day after the order was instituted, a nurse administers prednisone 5 mg by mouth. During an audit of the chart, the error is identified. The person most responsible for the error is the:

A.    nurse who transcribed the order incorrectly on the MAR.

B.    nurse who administered the erroneous dose.

C.   pharmacist who filled the order and provided the erroneous dose.

D.   facility because of its policy on transcription of medications.

99.   The nurse is assigned to care for eight clients. Two nonprofessionals are assigned to work with the nurse. Which statement is valid in this situation?

A.    The nurse may assign the two nonprofessionals to work independently with a client assignment.

B.    The nurse is responsible to supervise assistive personnel.

C.   Nonprofessionals aren't responsible for their own actions.

D.   Nonprofessionals don't require training before they work with clients.

100.            Which of the following strategies would the nurse manager include in a plan to assist an impaired colleague?

A.    Appoint a team to confront the colleague

B.    Initiate termination of the colleague

C.   Promote professional isolation

D.   Provide covert support of the substance abusing behavior

For answers and rationale click the link below:
PRACTICE TEST 2 - ANSWERS AND RATIONALE