NURSING
BOARD REVIEW QUESTIONS
BLOOD ADMINISTRATION
INTENSIVE NURSING PRACTICE: BLOOD ADMINISTRATION - QUESTIONS AND ANSWERS
1. Halfway through the administration of a unit of blood, a client complains of lumbar pain. The nurse should:
A. Obtain vital signs
B. Stop the transfusion
C. Assess the pain further
D. Increase the flow of normal saline
2. A nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. The nurse checks which of the following items carefully before beginning the transfusion to ensure that this has not happened?
A. Blood identification number
B. Expiration date
C. Blood group and type
D. Presence of clots
3. A nurse enters a client's room to assess the client, who began receiving a blood transfusion 45 minutes earlier. The client is flushed and dyspneic. On assessment the nurse auscuhates the presence of crackles in the lung bases. The nurse determines that this client most likely is experiencing which of the following complications of blood transfusion therapy?
A. Hypovolemia
B. Transfusion reaction
C. Fluid overload
D. Bacteremia
4. A client ordered to receive a transfusion has experienced a rash with pruritus during previous transfusions. The client asks the nurse whether it is safe to receive the transfusion. In formulating a response, the nurse incorporates the understanding that which of the following medications most likely will be ordered before the transfusion is begun?
A. Diphenhydramine (Benadryl)
B. Acetylsalicylic acid (ASA, aspirin)
C. Acetaminophen (Tylenol)
D. Ibuprofen (Motrin)
5. The physician orders 2 units of blood to be infused into a client who is bleeding. Before blood administration the nurse's highest priority should be:
A. Obtaining the client's vital signs
B. Allowing the blood to reach room temperature
C. Monitoring the hemoglobin and hematocrit levels
D. Determining proper typing and crossmatching of blood
ASSESSMENT
6. Before a prescribed intravenous solution that contains potassium chloride is administered, the assessment by the nurse that should be brought to the physician's attention would be:
A. Poor skin turgor with "tenting"
B. Behaviors indicating irritability and confusion
C. A urinary output of 200 ml during the previous shift
D. An oral intake of 300 ml of fluid during the previous shift
7. A client with a severe head injury is admitted after a motor vehicle accident. The admitting nurse reviews the emergency department nurse's notes and finds the client's Glasgow Coma Scale score to be 6. The client is in which neurologic state?
A. Coma
B. Locked-in syndrome
C. Vegetative
D. Drowsy but easily aroused
8. The finding that would most significantly indicate that a client is hypertensive is:
A. An extended Korotkoff's sound
B. A regular pulse of 92 beats per minute
C. A systolic blood pressure ranging from 140 to 150 mm Hg
D. A diastolic blood pressure that remains greater than 90 mm Hg
9. Which of the following statements about pain in children would the nurse identify as true?
A. Children have less pain tolerance than adults
B. Children cannot tell where it hurts
C. Children always tell the truth about pain
D. Children become accustomed to pain
10. The physician has just inserted a central line for total parenteral nutrition (TPN) into a client who has a perforated bowel. The physician asks the nurse to begin infusing lactated Ringer's solution. Prior to starting the infusion, the nurse should verify which of the following?
A. Clarity of the physician's order for I.V. solution
B. The temperature of the solution
C. The results of the chest X-ray taken after the insertion of the catheter
D. The rate of the I.V. infusion
11. Which of the following would the nurse do for a 4-year-old girl who has just had a lumbar puncture?
A. Administer narcotic analgesic for insertion site pain.
B. Encourage the parents to hold the child.
C. Ensure the child lies flat for at least 8 hours.
D. Place a sandbag over the puncture site for 3 hours.
12. The nurse should be aware that the correct order for physical assessment of the abdomenis
A. Inspect, auscultate, percuss and palpate
B. Inspect, palpate, auscultate and percuss
C. Inspect, percuss, palpate and auscultate
D. Inspect, palpate, percuss and auscultate
13. The description that should be used for the soft swishing sounds of normal breathing heard when the nurse auscultates a client's chest would be:
A. Fine crackles
B. Adventitious sounds
C. Vesicular breath sounds
D. Diminished breath sounds
14. The nurse identifies a client's responses to actual or potential health problems during which step of the nursing process?
A. Assessment
B. Analysis
C. Planning
D. Evaluation
15. A client begins a fecal fat analysis test on a Monday. The nurse should instruct the client to begin the 3-day stool collection on:
A. Monday.
B. Tuesday.
C. Wednesday.
D. Thursday.
16. A home health nurse notes excessive swallowing in a 7-year-old boy who had a tonsillectomy one week ago. Which of the following would be the nurse's priority intervention?
A. Examine the child's throat, as this indicates bleeding.
B. Administer extra fluids, as this indicates dehydration.
C. Administer aspirin, as this indicates pain.
D. Instruct the child to spit secretions instead of swallowing them.
17. While caring for the client with a burn injury, the nurse should observe for signs and symptoms of which complication believed to be due primarily to hypersecretion of gastric acid?
A. Paralytic ileus.
B. Gastric distention.
C. Hiatal hernia.
D. Gastrointestinal ulceration.
18. When assessing an adolescent female, the nurse observes the formation of breast buds. The nurse would document this as being in which of the following stages described by Tanner?
A. Stage 2
B. Stage 1
C. Stage 3
D. Stage 4
19. Nursing measures for the client who has had an MI include helping the client to avoid activity that results in Valsalva's maneuver. Valsalva's maneuver may cause cardiac dysrhythmias, increased venous pressure, increased intrathoracic pressure, and thrombi dislodgment. Which of the following actions would help prevent Valsalva's maneuver? Have the client:
A. Assume a side-lying position.
B. Clench her teeth while moving in bed.
C. Drink fluids through a straw.
D. Avoid holding her breath during activity.
20. The nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation rapidly drops. He complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Further assessment findings supporting the presence of a pneumothorax include:
A. diminished or absent breath sounds on the affected side.
B. paradoxical chest wall movement with respirations.
C. tracheal deviation to the unaffected side.
D. muffled or distant heart sounds.
21. The nurse needs to instruct an unlicensed assistant on how to collect a urine specimen from an indwelling catheter. Which of the following statements indicates that the assistant understands the instructions?
A. "I should collect urine from the catheter drainage bag at the end of the shift and place it in the specimen container."
B. "I will disconnect the drainage tube from the catheter and let urine run from the catheter into the specimen container."
C. "I will empty the catheter drainage bag, have the client drink some water, and an hour later collect the urine that drains into the bag."
D. "I will get a sterile syringe and remove urine from the catheter through the collection port to place in the specimen container."
22. When reviewing the laboratory test results of a child with nephrotic syndrome, which of the following would the nurse expect to find?
A. High platelet count
B. High urine specific gravity
C. Markedly increased serum protein
D. Elevated serum sodium
23. An 18-year-old woman reports to the health clinic with complaints of dark urine, fever, and flank pain. An initial nursing assessment of the patient would reveal which of the following EARLY symptoms of glomerulonephritis?
A. Polyuria.
B. Oliguria.
C. Polydipsia.
D. Enuresis.
24. Which finding would be least suggestive of necrotizing enterocolitis (NEC) in an infant?
A. Hepatomegaly
B. Distended abdomen
C. Gastric retention
D. Blood in the stool
25. 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.
26. The client is diagnosed with benign fibrocystic breast disease. Interventions to reduce discomfort from this disease include teaching the client to:
A. Increase her activity level.
B. Wear tight supporting garments.
C. Avoid caffeine.
D. Obtain estrogen therapy from her physician.
27. When teaching the parent of a school-age child about signs and symptoms of fever that require immediate notification of the physician, which description should the nurse include?
A. Burning or pain with urination
B. Complaints of a stiff neck
C. Fever disappearing for longer than 24 hours, then returning
D. History of febrile seizures
28. An adolescent girl who is receiving chemotherapy for leukemia is admitted for pneumonia. The adolescent's platelet count is 50,000
A. A sign over the bed that reads "NO NEEDLE STICKS AND NOTHING PER RECTUM"
B. Two peripheral I.V. intermittent infusion devices, one for blood draws and one for infusions
C. Administration of oxygen at a rate of 4 L/minute using a nonhumidified nasal cannula
D. Use of a tympanic membrane sensor to measure the client's temperature at the bedside
29. After 5 days of hospitalization, the client who is receiving morphine sulfate for pain control asks for pain medication with increasing frequency and exhibits increased anxiety and restlessness. His physical condition is stable. What is the probable cause of his behavior?
A. His morphine dosage is too high.
B. He is becoming addicted to the narcotic.
C. His coping mechanisms are exhausted.
D. He has developed tolerance to his narcotic dosage.
30. During a family therapy session, the nurse notes that the wife is sitting with her arms and legs crossed and her body turned away from her husband. This non-verbal behavior is an example of
A. incongruence.
B. distancing.
C. blocking.
D. cultural posturing.
31. The nurse assesses the client's burned right arm and notes increasing edema, absence of a radial pulse, and decreased sensation in the fingers. Based on these data, the nurse's priority response should be to:
A. Document findings and recheck in 1 hour.
B. Elevate extremity on one pillow.
C. Notify the physician immediately.
D. Implement passive range-of-motion exercises.
32. The nurse is caring for an 8-year-old with acute asthma exacerbation. Which of the following would be of greatest concern to the nurse?
A. The child's respiratory rate is now 24 breaths/minute.
B. Recent blood gas analysis indicates an oxygen saturation of 95%.
C. Before a respiratory therapy treatment, wheezing isn't heard on auscultation.
D. The child's mother reports that the child sometimes forgets to take the inhalers.
33. When monitoring a client's central venous pressure (CVP), the nurse knows that a normal CVP measurement is:
A. 2 cm H20.
B. 1 mm Hg.
C. 10 mm Hg.
D. 5 cm H20.
34. A client with a history of atrial fibrillation presents to the outpatient clinic with nausea, vomiting, heart rate of 55 beats/minute, and visual disturbances. The nurse would further assess this client for the possibility of which of the following conditions?
A. Digoxin toxicity
B. Angina
C. Heart failure
D. Depression
35. When assessing a patient for the potential development of hypovolemic shock, which of the following manifestations would the nurse most likely see first?
A. Nervousness and apprehension
B. Decreased urinary output
C. Systolic blood pressure below 90 mm Hg
D. Hypoventilation and tachycardia
36. The nurse is caring for several clients who have eating disorders. Based on appearance, how would the nurse distinguish bulimic clients from anorectic clients?
A. By their teeth
B. By body size and weight
C. By looking for Mallory-Weiss tears
D. The clients are indistinguishable upon physical examination.
37. The nurse is assessing an elderly client for dementia. Which of the following is a primary symptom of dementia?
A. Psychosis
B. Memory loss
C. Neurosis
D. Loss of impulse control
38. A mother tells the nurse that she wants to begin toilet training her 22-month-old child. The most important factor regarding toilet training that the nurse should stress to her is:
A. developmental readiness of the child.
B. consistency in approach.
C. the mother's positive attitude.
D. developmental level of the child's peers.
39. A nurse, while doing a physical assessment, shines a light into a patient's right eye and notes pupillary constriction in the left eye. The nurse should chart this response as
A. a direct reaction.
B. a consensual reaction.
C. accommodation.
D. pupillary convergence.
40. Which of the following assessments would be important for the nurse to make to determine whether or not a client is recovering as expected from spinal anesthesia?
A. Level of consciousness.
B. Rate and depth of respirations.
C. Rate of capillary refill in the toes.
D. Degree of response to pinpricks in the legs and toes.
41. When assessing a 3-year-old, which of the following tasks would the nurse expect the child to have mastered?
A. Riding a tricycle
B. Jumping rope
C. Printing first name
D. Tying shoelaces
42. The nurse observes that the client's total parenteral nutrition (TPN) solution is infusing too slowly. The nurse calculates that the client has received 300 mL less than was ordered for the day. The nurse should:
A. Increase the flow rate to infuse an additional 300 mL over the next hour.
B. Maintain the flow rate at the current rate and document any discrepancy in the chart.
C. Assess the infusion system, note the client's condition, and notify the physician.
D. Discontinue the solution and administer dextrose in 5% water until the infusion problem is resolved.
43. Which client should receive a private room?
A. A client with diabetes
B. A client with Cushing's disease
C. A client with Grave's disease
D. A client with gastric ulcers
44. A client is admitted with symptoms of a cerebrovascular accident. Nursing assessment data include: inability to move the right arm and leg, absence of muscle tone in the right arm and leg, and lack of knowledge about how to turn in bed. Based on these data, which of the following would be the most appropriate nursing diagnosis for this client?
A. Activity Intolerance.
B. Disturbed Sleep Pattern.
C. Impaired Physical Mobility.
D. Unilateral Neglect.
45. A client has cholelithiasis with possible obstruction of the common bile duct. Before the scheduled cholecystectomy, nutritional deficiencies and excesses should be corrected. A nutritional assessment should be conducted to determine whether the client:
A. Is deficient in vitamins A, D, and K
B. Eats adequate amounts of dietary fiber
C. Consumes excessive amounts of protein
D. Has excessive levels of potassium and folic acid
46. A client comes to the physician's office for a complete physical examination required for employment. The physician assesses the client's arms and legs for evidence of peripheral vascular disease. Which overall indicator of arm and leg circulation is the most commonly used?
A. Exercise testing
B. Ankle-brachial index
C. Limb blood pressure
D. Allen's test
47. A 50-year-old woman is treated in the emergency room for acute alcohol intoxication. She has a history of alcohol abuse. When performing an initial assessment on this patient, which information would be MOST important for the nurse to obtain?
A. When did the patient have her last drink?
B. How much alcohol has the patient consumed?
C. What has the patient been drinking?
D. How many years has the patient been drinking?
48. A positive Mantoux test indicates that the client:
A. is actively immune to tuberculosis.
B. has produced an immune response.
C. will develop full-blown tuberculosis.
D. has an active case of tuberculosis.
49. Which of the following findings is suggestive of myocardial infarction (MI)?
A. Elevated serum cholesterol value.
B. Elevated creatine phosphokinase (CPK) value.
C. Below-normal erythrocyte sedimentation rate.
D. Elevated white blood cell count.
50. After undergoing a barium enema, which of the following indicates that the infant has adequately evacuated the barium?
A. Absence of fecal mass in the lower abdomen.
B. Stools that progress from clay-colored to brown.
C. Bowel sounds of 30 per minute.
D. Stool guaiac that is negative.
51. A 9-month-old infant is admitted with diarrhea and deficient fluid volume. The nurse plans to assess this client's vital signs frequently. What other action would provide the most important assessment information?
A. Measuring the infant's body weight
B. Obtaining a stool specimen for analysis
C. Obtaining a urine specimen for analysis
D. Inspecting the infant's posterior fontanel
52. The infant's skin is inelastic and the upper abdomen is distended. To palpate the olive-like mass most easily, the nurse palpates the epigastrium just to the right of the umbilicus at which of the following times?
A. Just before the infant vomits.
B. While the infant is eating.
C. When infant is lying on the left side.
D. When the stomach is empty.
53. A 5 1/2-month-old infant is admitted to the hospital with a fever and a history of vomiting for 48 hours. In view of this infant's responses, the assessment by the nurse that would initially influence the child's care is:
A. Inspecting the baby's skin for poor turgor
B. Determining the baby's vital signs and weight
C. Checking the baby's neurologic status and urinary output
D. Asking the mother whether the baby is breastfed or bottle-fed
54. Which of the following is an early sign of heart failure in an infant with a congenital heart defect?
A. Tachypnea
B. Tachycardia
C. Poor weight gain
D. Pulmonary edema
55. A client is admitted to the emergency department with complaints of chest pain and shortness of breath. The nurse's assessment reveals jugular vein distention. The nurse knows that when a client has jugular vein distention, it's typically due to:
A. a neck tumor.
B. an electrolyte imbalance.
C. dehydration.
D. fluid overload.
56. The community health nurse makes a home visit to a 13-year-old boy who is disabled and who has three siblings younger than 6 years old. The nurse observes that the 6-month-old sister lies quietly in her crib, rarely smiles or vocalizes, and barely has her basic needs attended. The nurse should:
A. Place an aide in the home to assist with chores and care for the infant
B. Advise the mother that the child will be retarded if she is not stimulated
C. Ask the 13-year-old disabled brother to pay more attention to his sister
D. Encourage the mother to purchase appropriate toys manufactured for the baby's age level
57. When completing an assessment of a healthy adolescent client, which of the following would be most appropriate?
A. Obtain a detailed account of the adolescent’s prenatal and early developmental history.
B. Discuss sexual preferences and behaviors with the parents present for legal reasons.
C. Discuss the client’s smoking with parents present in the room.
D. Assess the adolescent in private; gather additional information from the parents.
58. A mother brings her 2-year-old adopted Korean child to the clinic for an initial checkup. The child has been living with the adopted family for several weeks. The nurse notes an irregular area of deep blue pigment on the child's buttocks extending into the sacral area. The nurse should:
A. Do nothing concerning this finding.
B. Ask the mother in private how the bruise occurred.
C. Notify social services of a case of possible child abuse.
D. Question the mother about the family's discipline style.
59. Correct preparation of the client for a Papanicolaou (Pap) smear would include which of the following measures?
A. The test should be scheduled while the client is menstruating.
B. The client should not bathe on the morning before the examination.
C. The woman should not douche on the morning before the examination.
D. The woman should take a laxative the night before the examination.
60. A 7-year-old is admitted to the emergency department following severe vomiting for the last 36 hours. Which of the following would the nurse expect diagnostic test results to reveal?
A. Metabolic alkalosis
B. Respiratory alkalosis
C. Respiratory acidosis
D. Metabolic acidosis
61. When attempting to reduce the risk of impaired skin integrity related to immobility in a toddler, which action should be avoided?
A. Gently massaging the skin with a lubricating substance
B. Spreading a thin layer of lotion over pressure points
C. Changing the toddler's position frequently
D. Cleaning the skin as often as necessary
62. A client is admitted to the emergency room with a cut finger that is bleeding profusely. She displays signs of alcohol intoxication, and a blood test confirms this. After the client's wound is sutured but before she leaves the emergency room, it would be best for the nurse to ensure that the client:
A. Takes a nap.
B. Does some exercising.
C. Restricts fluid intake.
D. Drinks generous amounts of black coffee.
63. A client is to be discharged from an acute care facility after treatment of right leg thrombophlebitis. The nurse notes that the client's leg is pain free, without redness or edema. The nurse's actions reflect which step in the nursing process?
A. Assessment
B. Analysis
C. Implementation
D. Evaluation
64. When developing a plan of home care for the client with multiple sclerosis, the nurse should teach the client about which of the following complications most likely to occur?
A. Ascites.
B. Contractures.
C. Fluid volume overload.
D. Myocardial infarction.
65. The nurse understands that a liver biopsy may be contraindicated in certain situations. Therefore, it is important for the nurse to assess the client for:
A. Confusion and disorientation
B. The presence of any infectious disease
C. A prothrombin time of less than 40% of normal
D. Foods high in vitamin K eaten before the biopsy
66. A mother asks the nurse if the lesions around her child's mouth could be impetigo. To verify the mother's suspicions, the nurse would look for:
A. Honey-colored crusts, vesicles, and reddish maculae on the skin.
B. Erythema and formation of pus around hair follicles.
C. Increased warmth, intense redness, swelling, and firmness of the skin.
D. Macular erythema with a sandpaper-like texture of the skin.
67. A client is receiving furosemide (Lasix) to relieve edema. The nurse should monitor the client for evidence of:
A. Negative nitrogen balance
B. Excessive loss of potassium ions
C. Excessive retention of sodium ions
D. Elevation of the urine-specific gravity
68. A client is admitted to the hospital following a burn injury to the left hand and arm. The client's burn is described as white and leathery with no blisters. Which degree of severity is this burn?
A. First-degree burn
B. Second-degree burn
C. Third-degree burn
D. Fourth-degree burn
69. The nurse must apply an elastic bandage to a client's ankle and calf. She should apply the bandage beginning at the client's:
A. foot.
B. ankle.
C. lower thigh.
D. knee.
70. In planning the care of an infant undergoing phototherapy for hyperbilirubinemia, which of the following would be least appropriate?
A. Repositioning the infant frequently to expose all body surfaces
B. Obtaining frequent serum bilirubin levels
C. Shielding the infant's eyes with an opaque mask to prevent exposure to the light
D. Performing frequent visual assessments of jaundice
71. Which of the following immunizations would be inappropriate for an adolescent as a component of preventive care?
A. A tetanus-diphtheria (Td) vaccine, given 10 years after the most recent childhood diphtheria, tetanus toxoids, and acellular pertussis (DTaP) vaccine
B. A second measles-mumps-rubella (MMR) vaccine
C. A tuberculin skin test every other year
D. The hepatitis B vaccine, if not received earlier
72. While a client with hypertension is being assessed, he says to the nurse, "I really don't know why I'm here. I feel fine and haven't had any symptoms." The nurse would explain to the client that symptoms of hypertension:
A. Are often not present.
B. Signify a high risk of stroke.
C. Occur only with malignant hypertension.
D. Appear after irreversible kidney damage has occurred.
73. After undergoing a transurethral resection of the prostate to treat benign prostatic hyperplasia, a client is returned to his room with continuous bladder irrigation in place. One day later, the client reports bladder pain. What should the nurse do first?
A. Increase the I.V. flow rate.
B. Notify the physician immediately.
C. Assess the irrigation catheter for patency and drainage.
D. Administer meperidine (Demerol) as prescribed.
74. A client with severe left-sided heart failure has a decrease in the total amount of blood ejected per minute. This quantity is known as:
A. stroke volume.
B. ejection fraction.
C. cardiac output.
D. heart rate.
75. Which of the following should the nurse ask first when a mother states that her child is allergic to amoxicillin?
A. "What happens when she takes amoxicillin?"
B. "Why do you think she is allergic?"
C. "Does anyone else in the family have allergies?"
D. "Are you sure it was an allergic reaction?"
76. When performing nursing care, the nurse would expect which person to have the highest risk for fluid imbalance?
A. Middle-aged obese female
B. 35-year-old athletic male
C. Elderly male
D. Infant
77. The nurse is evaluating a client who is complaining of shortness of breath. The client's respiratory rate is 26 breaths/minute so the nurse documents that he is tachypneic. The nurse understands that tachypnea means:
A. frequent bowel sounds.
B. heart rate greater than 100 beats/minute
C. hyperventilation.
D. respiratory rate greater than 20 breaths/minute
78. Which of the following changes is demonstrated when a nurse helps a young mother adjust to the birth of her child?
A. Unplanned
B. Situational
C. Maturational
D. Physiologic
79. During the initial assessment of a client, the nurse percusses dullness. The nurse understands that dullness on percussion can be described as:
A. flat, with high pitch and short duration.
B. loud, with high pitch and moderately long duration.
C. moderate-to-loud, with low pitch and long duration.
D. soft to moderately loud, with moderate pitch and duration.
80. Which of the following rationales best explains the need for teaching the parents about monitoring the temperature of the feeding formula for a child after undergoing a cleft palate repair?
A. The lack of nerve endings in the new palate increases the child's risk for burns.
B. Colder temperature formula is needed to prevent infection of the suture line.
C. Using the proper temperature ensures the use of the proper feeding technique.
D. The temperature of the formula directly affects the amount of pain experienced.
81. A client suffers adult respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?
A. Kinking of the ventilator tubing
B. A disconnected ventilator tube
C. An endotracheal cuff leak
D. A change in the oxygen concentration without resetting the oxygen level alarm
82. During the evening shift on the day of the client's surgery, the nasogastric tube drains 500 mL of green-brown fluid. The nurse should:
A. Call the physician immediately.
B. Increase the intravenous infusion rate.
C. Record the amount of drainage on the client's chart.
D. Irrigate the tube with normal saline solution.
83. Lad results indicate that the client's serum aminophylline level is 17 mcg/ml. The nurse recognizes that the aminophylline level is:
A. Within therapeutic range
B. Too high and should be reported
C. Questionable and should be repeated
D. Too low to be therapeutic
84. The nurse is teaching the client the appropriate way to use an inhaler. Which action indicates the client needs additional teaching?
A. The client takes a deep breath and holds it for 3 or 4 seconds.
B. The client palces the inhaler mouthpiece beyond his lips.
C. The client inhales with lips tightly sealed to mouthpiece.
D. The client exhales slowly using purse lipped breathing.
85. When performing a physical assessment on an 18-month-old child, which of the following would be best?
A. Have the mother hold the toddler on her lap.
B. Assess the respiratory and cardiac systems first.
C. Carry out the assessment from head to toe.
D. Assess motor function by having the child run and walk.
86. An 86-year-old male is admitted to the hospital for renal insufficiency. The First night he becomes extremely disoriented, confused and combative after being given a low dose tricyclic antidepressant. The nurse should be aware that such behavior is indicative of
A. dementia.
B. delirium.
C. psychosis.
D. depression.
87. A woman has a thyroidectomy and is admitted to the recovery room in stable condition. Which of the following assessments, if made by the nurse, would be considered an ABNORMAL finding?
A. The patient makes noises when she breathes.
B. The patient complains of pain at the surgical site.
C. The patient complains that she is thirsty.
D. The patient is sleepy from anesthesia.
88. During a routine physical examination, an abdominal aortic aneurysm is diagnosed. The client is immediately admitted to the hospital, and surgery is scheduled for the next morning. When performing the admission assessment the nurse should expect:
A. Severe radiating abdominal pain
B. Cyanosis and symptoms of shock
C. A pattern of visible peristaltic waves
D. A palpable pulsating abdominal mass
89. A client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal?
A. Inadequate vitamin D intake
B. Inadequate protein intake
C. Inadequate massaging of the affected area
D. Low calcium level
90. Which type of evaluation occurs continuously throughout the teaching and learning process?
A. Formative
B. Retrospective
C. Summative
D. Informative
91. To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR), the nurse should palpate which pulse site?
A. Radial
B. Apical
C. Carotid
D. Brachial
92. Which of the following groups of clients is at an increased risk for developing a wound infection?
A. Clients who require frequent pain medication
B. Clients who are 15 lb (6.8 kg) overweight
C. Clients who ambulate after the first postoperative day
D. Clients who are undernourished
93. When assessing a client with Guillain-Barrè syndrome, the nurse should anticipate which sign or symptom?
A. Paresthesia and weakness in the legs
B. Hyperactive deep tendon reflexes
C. Rapid arm and leg movements
D. Emotional disturbances
94. A 30-year-old client is admitted with a fracture sustained in a fall. To alleviate pain, the physician prescribes meperidine hydrochloride (Demerol), 75 mg I.M. stat. When preparing to administer the injection, the nurse keeps in mind that the maximum volume of drug that can be administered to the client in a single I.M. injection is:
A. 2 ml.
B. 3 ml.
C. 4 ml.
D. 5 ml.
95. The nurse is assigned to care for a postoperative client who has diabetes mellitus. During the assessment interview, the client reports that he's impotent and says that he's concerned about its effect on his marriage. In planning this client's care, the most appropriate intervention would be to:
A. encourage the client to ask questions about personal sexuality.
B. provide time for privacy.
C. provide support for the spouse or significant other.
D. suggest referral to a sex counselor or other appropriate professional.
96. A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which of the following contributing factors would the nurse recognize as most important?
A. A history of increased aspirin use
B. Recent pelvic surgery
C. An active daily walking program
D. A history of diabetes
97. The nurse cares for a patient being treated for a pneumothorax. A patient has two chest tubes connected to a Pleur-evac drainage system by a "Y" connector. Which of the following actions should the nurse take before ambulating the patient?
A. Clamp the upper chest tube and leave the lower chest tube unclamped.
B. Clamp both the upper and lower chest tubes.
C. Leave both the upper and lower chest tubes unclamped.
D. Clamp the lower chest tube and leave the upper chest tube unclamped.
98. A client hospitalized with acute glomerulonephritis has a positive ASO titer. the nurse understands that the client's current illness is due to a:
A. History of uncotrolled hypertension
B. Prior bacterial infection
C. Prolonged elevation in blood glucose
D. Drug reaction that led to muscle breakdown
99. Which of the following should the school nurse do first when a child with diabetes mellitus becomes unresponsive during recess?
A. Administer glucagon as prescribed.
B. Administer 3 to 6 ounces of orange juice.
C. Give the child milk and peanut butter crackers.
D. Immediately transport the child by car to the hospital.
100.When assessing a patient for posture and stature, the nurse recognizes that the patient is lying still and complaining of pain. Slight jarring of the bed causes agonizing pain. The nurse assesses that the origin of the pain may be
A. renal.
B. biliary.
C. peritoneal.
D. meningeal.
ANSWERS
1. B
2. B
3. C
4. A
5. D
6. C
7. A
8. D
9. A
10. C
11. B
12. A
13. C
14. B
15. D
16. A
17. D
18. A
19. D
20. B
21. D
22. A
23. B
24. A
25. B
26. C
27. B
28. C
29. D
30. B
31. C
32. C
33. D
34. A
35. A
36. B
37. B
38. A
39. B
40. D
41. A
42. C
43. C
44. C
45. A
46. B
47. A
48. B
49. B
50. B
51. A
52. B
53. B
54. B
55. D
56. A
57. D
58. A
59. C
60. A
61. B
62. A
63. D
64. B
65. C
66. A
67. B
68. C
69. A
70. D
71. C
72. A
73. C
74. C
75. A
76. D
77. D
78. B
79. D
80. A
81. A
82. C
83. A
84. C
85. A
86. B
87. A
88. D
89. B
90. A
91. C
92. D
93. A
94. D
95. D
96. B
97. C
98. B
99. A
100. C
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