INTENSIVE NURSING PRACTICE - PART 2
QUESTIONS AND ANSWERS
1. When assessing a 13-month-old infant with dehydration and metabolic acidosis, the nurse should expect to see which clinical manifestation?
A. Reduced white blood cell count
B. Reduced platelet count
C. Shallow respirations
D. Tachypnea
2. During the insertion of a rigid scope for bronchoscopy, a client experiences a vasovagal response. The nurse should expect:
A. the client's pupils to become dilated.
B. the client to experience bronchodilation.
C. a decrease in the client's gastric secretions.
D. a drop in the client's heart rate.
3. A client who has a potassium level of 6 mEq/L should be treated with:
A. antacids.
B. I.V. fluids.
C. fluid restriction.
D. sodium polystyrene sulfonate (Kayexalate).
4. The occupational health nurse is screening employees for symptoms of carpal tunnel syndrome. Symptoms indicative of carpal tunnel syndrome most commonly include:
A. Paresthesia in the thumb and first and second fingers.
B. Difficulty flexing fingers.
C. Decreased capillary refilling.
D. Numbness in the forearm.
5. A 72-year-old man is admitted to the hospital complaining of right-sided weakness and difficulty speaking. The patient tells the nurse that he fell while at home. It would be MOST important for the nurse's initial assessment of the patient to include evaluation for
A. nutritional deficiencies.
B. ambulation problems.
C. hearing difficulties.
D. head injury.
6. The nurse must obtain a urine specimen from an infant. The nurse can best obtain a clean-catch specimen by:
A. applying a pediatric urine collector to dry skin.
B. placing the infant on a pediatric bedpan.
C. inserting an indwelling urinary catheter.
D. wringing out a cloth diaper after the infant voids.
7. A 3-month-old with meningococcal meningitis has just been admitted to the pediatric unit. Which nursing intervention has the highest priority?
A. Instituting droplet precautions
B. Administering acetaminophen (Tylenol)
C. Obtaining history information from the parents
D. Orienting the parents to the pediatric unit
8. A client appears very anxious, with respirations that are shallow and very rapid (40 per minute). The client complains of feeling dizzy and light-headed and of having tingling sensations of the fingertips and around the lips. The nurse should recognize that the client's complaints are probably related to:
A. Eupnea
B. Hyperventilation
C. Kussmaul's respirations
D. Carbon dioxide intoxication
9. The nurse performs an assessment of a newborn boy. Which of the following observations, by the nurse, would be considered an ABNORMAL finding in a newborn?
A. He breathes 40 times per minute with short periods of apnea.
B. His heart rate is 140 beats per minute with variation during sleeping and waking states.
C. A sudden loud noise causes abduction of his arms and flexion of his elbows.
D. Stroking the outer sole of his foot upwards causes his toes to curl downward.
10. A Foley catheter operates by the principle of:
A. Inertia
B. Gravity
C. Diffusion
D. Osmosis
11. On the first day following a right pneumonectomy a male client suddenly sits straight up in bed. His respirations are labored, and he is making a crowing sound. His skin is pale, cool, and moist. Immediately the nurse should:
A. Notify the physician
B. Auscultate the left lung
C. Inspect the incision for bleeding
D. Check the chest tube for patency
12. A school-age child has a fever, joint inflammation, and a nonpruritic rash. Knowing that these are signs of rheumatic fever, the nurse should ask the parents:
A. "Has your child recently been exposed to other children with rheumatic fever?"
B. "Has your child had strep throat recently?"
C. "Does your child have a congenital heart defect?"
D. "Is your child's Haemophilus influenzae vaccine up-to-date?"
13. An adolescent has an order for placement of a pulse oximeter. To ensure accuracy of the pulse oximeter reading, the nurse should:
A. Place the probe on a finger or earlobe
B. Calibrate the oximeter at least every 8 hours
C. Place the probe on the abdomen or upper leg
D. After application wait 30 minutes before obtaining a reading
14. Surgery is performed on a client with a parotid tumor. The postoperative arterial blood gas values are pH 7.32; PCO2 53 mm Hg; HCO3 25 mEq/L. The nurse should:
A. Obtain a medical order for the administration of a diuretic
B. Have the client breathe into a rebreather bag at a slow rate
C. Encourage the client to cough productively and take deep breaths
D. Obtain a medical order for the administration of sodium bicarbonate
15. Which of the following would be least likely to affect the parent-child relationship?
A. Readiness for the pregnancy
B. Nature of the pregnancy
C. Maturity of the parents
D. Grandparent support
16. Which intervention provides the most accurate information about an infant's hydration status?
A. Monitoring the infant's vital signs
B. Accurately measuring intake and output
C. Monitoring serum electrolytes
D. Weighing the infant daily
17. An infant is diagnosed with a congenital hip dislocation. On assessment, the nurse expects to note:
A. symmetrical thigh and gluteal folds.
B. Ortolani's sign.
C. increased hip abduction.
D. femoral lengthening.
18. Which of the following temperament attributes is best defined as the regularity in the timing of physiologic functions?
A. Rhythmicity
B. Approach--withdrawal
C. Adaptability
D. Intensity of reaction
19. The American Cancer Society (ACS) recommends routine screening to detect colorectal cancer. Which screening test for colorectal cancer should the nurse recommend?
A. Carcinoembryonic antigen (CEA) test after age 50
B. Proctosigmoidoscopy after age 30
C. Annual digital examination after age 40
D. Barium enema after age 20
20. The nurse is conducting a mental status examination on a client with a cognitive disorder. Which of the following statements does the nurse judge to be an impairment in abstract thinking? The client's:
A. Ability to remember her wedding day.
B. Inability to find a similarity between a bird and a butterfly.
C. Memories regarding her vacation 5 years ago.
D. Inability to state her home address.
21. To which of the following nursing diagnoses would a nurse give priority when caring for a patient who is not eating or bathing and refuses to leave the house since the death of her daughter a year ago?
A. Anxiety related to fear of death
B. Self-care deficit related to loss
C. Anticipatory grieving related to fear of social interaction
D. Dysfunctional grieving related to loss
22. A client's monitor shows a PQRST wave for each beat and indicates a rate of 120. The rhythm is regular. The nurse should note that the client is experiencing:
A. Atrial fibrillation
B. Sinus tachycardia
C. Ventricular fibrillation
D. First-degree atrioventricular block
23. When educating the client with adult-onset diabetes mellitus about activity level, the nurse bases the information on the knowledge that exercise affects the body's physiologic functioning relative to glucose usage in which of the following ways?
A. Exercise helps avoid hypoglycemia.
B. Exercise stimulates insulin overproduction.
C. Exercise decreases the renal threshold for glucose.
D. Exercise increases the use of glucose by muscles.
24. When performing a neurologic assessment on a client, the nurse finds that the client's pupils are fixed and dilated. What does this assessment of the client's eyes indicate?
A. The client is permanently paralyzed.
B. The client is going to be blind as a result of an injury.
C. The client probably has meningitis.
D. The client has received a significant brain injury.
25. Which of the following clinical manifestations would be most indicative of complete arterial obstruction in the lower extremities?
A. Aching pain.
B. Burning sensations.
C. Numbness and tingling.
D. Coldness.
26. Which of the following techniques would the nurse use first to determine if a nasogastric tube is positioned in the stomach?
A. Aspirating with a syringe and observing for the return of gastric contents.
B. Irrigating with normal saline and observing for the return of solution.
C. Placing the tube's free end in water and observing for air bubbles.
D. Instilling air and auscultating over the epigastric area for the presence of the tube.
27. To help control pain during coughing for a client who has had a lobectomy, the nurse should:
A. Place the bed in slight Trendelenburg's position and help the client turn onto her operative side to splint the incision.
B. Raise the bed to semi-Fowler's position and place one hand on the client's back, on the left side, and one hand under the incision.
C. Keep the bed flat and tell the client to place her hands over the incision before taking a deep breath.
D. Raise the bed to complete Fowler's position and help the client turn onto her operative side to splint the incision.
28. When monitoring a child for respiratory distress, which of the following would be the earliest sign to report?
A. Restlessness
B. Cyanosis
C. Dyspnea
D. Fever
29. Clients with diabetes mellitus require frequent vision assessment. The nurse should instruct the client about which of the following eye problems most likely to be associated with diabetes mellitus?
A. Cataracts.
B. Retinopathy.
C. Astigmatism.
D. Glaucoma.
30. When assessing a client with cellulitis of the right leg, which of the following would the nurse expect to find?
A. Painful skin that is swollen and pale in color
B. Cold, red skin
C. Small, localized blackened area of skin
D. Red, swollen skin with inflammation spreading to surrounding tissues
31. A child, recently returned from a camping trip, complains of a rash, chills, fever, and a headache and is taken to the clinic by the parents. The nurse in the clinic recognizes that this child's history and physical assessment should include:
A. A history of allergies and duration of symptoms
B. A developmental screening and history of exposure to chickenpox
C. Sports played on the trip and when the child has to return to school
D. The date the child received a flu vaccination and a history of any sunburn
32. Which of the following assessment findings would the nurse observe first in a patient who is undergoing peritoneal dialysis and is developing peritonitis?
A. Dialysate leakage at catheter site
B. Insufficient flow of dialysate
C. Cloudy dialysate returns
D. Increased dialysate returns
33. After gathering all necessary equipment and setting up the supplies, which of the following would be the first step in performing endotracheal (ET) or tracheal suctioning in an infant?
A. Provide extra oxygen by using a ventilator or through manual bagging.
B. Insert a suction catheter to the appropriate measured length.
C. Insert a few drops of sterile saline solution.
D. Put on clean gloves.
34. Which of the following measures would be most helpful for the infant with gastroesophageal reflux?
A. Thickening the formula
B. Less frequent burping
C. Using smaller nipple holes
D. Positioning supine after feeding
35. The nurse is changing a client's dressing. Which observation of the wound warrants immediate physician notification?
A. Approximated wound edges
B. Yellow, purulent drainage
C. Suture in place
D. Pink granulation tissue
36. To assess the client's dorsalis pedis pulse, the nurse should palpate the:
A. Medial surface of the ankle.
B. Lateral surface of the ankle.
C. Ventral aspect of the top of the foot.
D. Medial aspect of the dorsum of the foot.
37. Which of the following activities should the nurse encourage the client with a peptic ulcer to avoid?
A. Chewing gum.
B. Smoking cigarettes.
C. Eating chocolate.
D. Taking acetaminophen (Tylenol).
38. When caring for a client with a 3-cm stage 1 pressure ulcer on the coccyx, which of the following actions can the nurse institute independently?
A. Using a povidone-iodine wash on the ulceration three times per day
B. Using a normal saline solution and applying a protective dressing as necessary
C. Applying an antibiotic cream to the area three times per day
D. Massaging the area with an astringent every 2 hours
39. A client returns from a myelogram, for which an iodized oil (Pantopaque) was used. Which one of the following nursing measures would be included in his care?
A. Bed rest with bathroom privileges.
B. Restricted fluid intake.
C. Head of the bed elevated 45 degrees.
D. Assessment of lower extremity movement and sensation.
40. When obtaining a tympanic temperature in a 2-year-old, in which of the following directions would the nurse pull on the earlobe to straighten the ear canal?
A. Down and back
B. Up and forward
C. Back and up
D. Forward and down
41. A 5-month-old infant is brought to the clinic by the mother who reports that he has nasal congestion, symptoms of a cold, fever, and difficulty breathing. The nurse should first:
A. ask for more history information.
B. perform a respiratory assessment.
C. notify the available physician.
D. take vital signs, including temperature.
42. A 13-year-old may have appendicitis. Which of the following symptoms would help determine the child's condition?
A. The severity, location, and movement of pain
B. The degree of fever
C. A history of vomiting and diarrhea, if present
D. A history of irritability and lethargy
43. When assessing a 7-month-old, which of the following reflexes would the nurse expect to be present?
A. Plantar grasp
B. Palmar grasp
C. Tonic neck
D. Moro
44. To locate the point of maximum impulse (PMI) of a patient's heart, the nurse's hand (fingertips) should be placed over which of the following locations?
A. The fifth intercostal space directly over the sternum.
B. The second intercostal space to the right of the sternum.
C. The second intercostal space to the left of the sternum.
D. The fifth intercostal space at the midclavicular line.
45. A 16-year-old who is depressed cheers up and gives her teddy bear to her favorite nurse. Which of the following is the priority for the nurse at this time?
A. Assess the adolescent for possible suicidal ideation
B. Tell her mother to call for a psychiatric referral
C. Give the bear back and discuss transitional objects
D. Praise her mood change and her passage from childhood
46. Pain control is an important nursing goal for the client with pancreatitis. Which of the following medications would the nurse plan to administer in this situation?
A. Meperidine hydrochloride (Demerol).
B. Cimetidine (Tagamet).
C. Morphine sulfate.
D. Codeine sulfate.
47. A client is at risk for developing a pressure ulcer. The first warning of an impending pressure ulcer is when pressure applied to skin turns it:
A. Bluish.
B. Reddish.
C. Whitish.
D. Yellowish.
48. The nurse is assessing a client with heart failure. The breath sounds commonly auscultated in clients with heart failure are:
A. tracheal.
B. fine crackles.
C. coarse crackles.
D. friction rubs.
49. A client with fever, weight loss, and watery diarrhea is being admitted to the health care facility. While assessing the client, a nurse inspects the client's abdomen and notices that it's scaphoid. Additional assessment should proceed in which order?
A. Auscultation, percussion, and palpation
B. Palpation, percussion, and auscultation
C. Percussion, palpation, and auscultation
D. Palpation, auscultation, and percussion
50. As part of the annual health screening, the nurse visits the eighth-grade physical education classes and asks each student to bend forward at the waist with the back parallel to the floor and the hands together at midline. For which of the following is the nurse assessing?
A. Slipped epiphysis.
B. Developmental dysplasia of hip.
C. Idiopathic scoliosis.
D. Physical dexterity.
51. A client receives meperidine (Demerol) 50 mg I.M. for relief of surgical pain. Thirty minutes later, the nurse asks the client if the pain is relieved. Which step of the nursing process is the nurse using?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
52. Which of the following statements, if voiced by the parents of a female child receiving cotrimoxazole (Septra/Bactrim) for a urinary tract infection, would indicate the need for additional teaching?
A. "We'll make arrangements to have her WBC count checked routinely."
B. "We'll continue to give her the medication until the drug is finished."
C. "We'll try to make sure that she doesn't go outside in the sun."
D. "We'll call the physician immediately if a rash occurs."
53. A client has emergency surgery for a ruptured appendix. After assessing that the client is manifesting symptoms of shock the nurse should:
A. Prepare for a blood transfusion
B. Notify the physician immediately
C. Elevate the head of the bed 30 degrees
D. Administer the oxygen prescribed postoperatively
54. The nurse is about to give an I.M. injection to a 2-year-old child. Which site should be avoided?
A. Vastus lateralis muscle
B. Ventrogluteal muscle
C. Dorsogluteal muscle
D. Deltoid muscle
55. During the insertion of a nasogastric tube, the nurse would evaluate that the client was experiencing difficulty if the client demonstrated:
A. Choking
B. Flushing
C. Gagging
D. Cyanosis
56. The client underwent a bowel resection and was in the post-anesthesia recovery unit for 1 hour. She returns from the recovery room with an intravenous line, a nasogastric tube, and a Foley catheter in place. She complains of pain and asks for medication. What action should the nurse take first?
A. Administer the ordered narcotic.
B. Establish the location and severity of pain.
C. Determine if she was medicated for pain in the post-anesthesia recovery unit.
D. Reposition her and give her a back rub.
57. A client is diagnosed as having a peptic ulcer. The nurse would expect that the client's pain:
A. Occurs 1 to 3 hours after meals
B. Is intensified when vomiting occurs
C. Increases when fatty foods are ingested
D. Begins in the epigastrium and radiates to the abdomen
58. A 3-month-old infant just had a cleft lip and palate repair. To prevent trauma to the operative site, the nurse should do which of the following?
A. Give the baby a pacifier to help soothe him.
B. Lie the baby in the prone position.
C. Place the infant's arms in soft elbow restraints.
D. Avoid touching the suture line, even to clean.
59. When assessing the child with an acute asthmatic attack, which of the following would the nurse expect to find?
A. Hyperresonance on chest percussion
B. Increased oxygen saturation
C. Inspiration longer than expiration
D. Elevated forced vital capacity
60. Which of the following techniques enhances breath sound auscultation?
A. Warming the stethoscope
B. Wetting the stethoscope
C. Listening with the diaphragm
D. Listening with the bell
61. Following a gastrojejunostomy (Billroth II) for cancer of the stomach, a client progresses to a regular diet. After eating lunch the client becomes diaphoretic and has palpitations. The symptoms are probably the result of:
A. An intolerance to fatty foods
B. The dehiscence of the surgical incision
C. An extracellular fluid shift into the bowel
D. Diminished peristalsis in the small intestine
62. Which of the following chloride levels on a sweat test would confirm the diagnosis of cystic fibrosis?
A. Greater than 60 mEq/L
B. 20 mEq/L or slightly less
C. 20 to 30 mEq/L
D. 50 to 60 mEq/L
63. When performing an admission assessment on a newly admitted client, the nurse percusses resonance. The nurse knows that resonance heard on percussion is most commonly heard over which organ?
A. Heart
B. Liver
C. Lung
D. Spleen
64. Which intervention takes priority when admitting an infant with acute gastroenteritis?
A. Obtaining a stool specimen
B. Weighing the infant
C. Offering the infant clear liquids
D. Obtaining a history of the illness
65. For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These assessments indicate which nursing diagnosis?
A. Impaired urinary elimination
B. Deficient fluid volume
C. Imbalanced nutrition: Less than body requirements
D. Excessive fluid volume
66. The parents of an adolescent girl have recently learned that their daughter has a terminal illness. At first, as they try to cope, they display avoidance behaviors. Then they demonstrate behaviors that indicate possible acceptance of the diagnosis. Which behavior would indicate acceptance?
A. Failure to recognize the seriousness of the child's condition despite physical evidence
B. Intellectualization about the illness in areas unrelated to the child's condition
C. Expression of feelings, such as sorrow and anger, about the child's condition
D. Avoidance of staff, family members, or the child
67. An arterial blood gas (ABG) is ordered for a 46-year-old man following a myocardial infarction. After obtaining the ABG, which of the following measures would be ESSENTIAL for the nurse to implement?
A. Obtain ice for the specimen.
B. Apply a sterile dressing to the site.
C. Apply direct pressure to the site.
D. Observe the site for hematoma formation.
68. Which electrolyte imbalance would a nurse expect when assessing a patient with bulimia?
A. Hyperkalemia
B. Hypokalemia
C. Hypercalcemia
D. Hypocalcemia
69. A 5-year-old child is being admitted to same-day surgery for a tonsillectomy and adenoidectomy. The nurse should assess for which of the following when admitting a client for this particular procedure?
A. Nasal abnormalities
B. Recent exposure to any communicable disease
C. Immunization history
D. The presence of any loose teeth
70. When teaching a client with peripheral vascular disease about foot care, the nurse should include which instruction?
A. Avoid using cornstarch on the feet.
B. Avoid wearing canvas shoes.
C. Avoid using a nail clipper to cut toenails.
D. Avoid wearing cotton socks.
71. Before administering a tube feeding to a toddler, which of the following methods should the nurse use to check the placement of a nasogastric (NG) tube?
A. Abdominal X-rays
B. Injection of a small amount of air while listening with a stethoscope over the abdominal area
C. A check of the pH of fluid aspirated from the tube
D. Visualization of the measurement mark on the tube made at the time of insertion
72. A 65-year-old woman is recovering from a right below-the-knee amputation. The patient observes the "figure eight" bandage on her residual limb. She asks the nurse why the bandage is applied in this manner. Which of the following explanations, if made by the nurse, is MOST accurate?
A. "It decreases the possibility of infection."
B. "It helps to minimize postoperative pain."
C. "It reduces the possibility of clot formation."
D. "It reduces postoperative swelling."
73. A client diagnosed with a peptic ulcer undergoes an upper gastrointestinal endoscopy to help the physician visualize the ulcer's location and severity. Immediately after the endoscopy, what would be a priority for the nurse to assess?
A. Return of the gag reflex.
B. Bowel sounds.
C. Peripheral pulses.
D. Intake and output.
74. Which signs and symptoms suggest that a client's abdominal aortic aneurysm is extending?
A. Increased abdominal and back pain
B. Decreased pulse rate and blood pressure
C. Retrosternal back pain radiating to the left arm
D. Elevated blood pressure and rapid respirations
75. When preparing the client with hepatitis A for extended convalescence, the nurse teaches the client about problems that may occur. The nurse knows that the client has understood the teaching when he says that he is most likely to have difficulty:
A. Controlling abdominal pain.
B. Maintaining a regular bowel elimination pattern.
C. Preventing respiratory complications.
D. Maintaining a positive, optimistic outlook.
76. The nurse is performing an assessment on a client who has developed a paralytic ileus. The client's bowel sounds will be:
A. hyperactive.
B. hypoactive.
C. high-pitched.
D. blowing.
77. Which of the following would lead the nurse to suspect increasing intracranial pressure in an infant in the earlier stages?
A. Tense bulging fontanel
B. Decreased pupil size
C. Low pitched cry
D. Vomiting
78. Which nursing measure would be most effective in helping the client cough and deep breathe after a cholecystectomy?
A. Having the client take rapid, shallow breaths to decrease pain.
B. Having the client lay on the left side while coughing and deep breathing.
C. Teaching the client to use a folded blanket or pillow to splint the incision.
D. Withholding pain medication so the client can be alert enough to follow the nurse's instructions.
79. Which of the following assessment findings would be exhibited in a child with Cushing syndrome?
A. Increased susceptibility to infection and virilization
B. Decreased appetite and paleness
C. Decreased blood pressure and acidosis
D. Hypoglycemia and skin thickening
80. When caring for the pregnant adolescent, which of the following is the primary goal?
A. Obtaining prenatal care
B. Promoting nutrition
C. Understanding body changes
D. Preventing secondary pregnancy
81. The correct procedure for auscultating the client's abdomen for bowel sounds would include:
A. Palpating the abdomen first to determine correct stethoscope placement.
B. Encouraging the client to cough to stimulate movement of fluid and air through the abdomen.
C. Placing the client on the left side to aid auscultation.
D. Listening for 5 minutes in all four quadrants to confirm absence of bowel sounds.
82. During auscultation of the heart, the nurse would expect the first heart sound (S1) to be the loudest at the:
A. Apex of the heart
B. Base of the heart
C. Left lateral border
D. Right lateral border
83. While assessing the incision of a client who had surgery 2 weeks ago, the nurse observes that the suture line has a shiny, light pink appearance. Which of the following steps would the nurse take next?
A. Notify the physician because the wound may be dehiscing.
B. Apply normal saline solution to keep the wound moist.
C. Do nothing because this is granulation tissue.
D. Prepare the client for debridement of the suture line.
84. Which of the following explanations would be included when teaching the parents of a child with autosomal recessive disorder?
A. There is a 25% chance of child being affected
B. The disorder usually affects male children
C. There are no carriers, only affected persons
D. Only one of the parents is affected
85. A 23-month-old child is brought to the emergency department with suspected croup. Which assessment finding reflects increasing respiratory distress?
A. Intercostal retractions
B. Bradycardia
C. Decreased level of consciousness
D. Flushed skin
86. 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?
A. "The pain associated with a heart attack is much more severe."
B. "The pain associated with a heart attack radiates into the jaw and down the left arm."
C. "It is impossible to differentiate anginal pain from that of a heart attack without an ECG."
D. "The pain of angina is usually relieved by resting or lying down."
87. An infant has undergone surgery to remove a myelomeningocele. To detect increased intracranial pressure (ICP) as early as possible, the nurse should be alert for which of the following postoperative findings?
A. Decreased urine output
B. Increased heart rate
C. Bulging fontanels
D. Sunken eyeballs
88. Which of the following assessments would be most supportive of the nursing diagnosis, Impaired skin integrity related to purulent wound drainage?
A. Heart rate of 88 beats/minute
B. Wound healing by first intention
C. Oral temperature of 101
89. To test a school-ager's sense of conservation, which of the following would the nurse do?
A. Show two equal-length pencils side by side, then move them out of alignment to see if the child realizes they are still the same length.
B. Give child a group of numbered blocks and have child arrange them according to some ordinal scale.
C. Give child a mixture of stamps, wrappers, and shells and have child group them according to some classification system.
D. State a situation to the child, then have the child anticipate the consequences and rethink the action in a different direction.
90. The nurse is caring for a client who was found huddled in her apartment by the police. The client stares toward one corner of the room and seems to be responding to something not visible to others. She appears hyperalert and scared. How would the nurse assess the situation?
A. The client may be hallucinating.
B. The client is suicidal.
C. Nothing is wrong because the client isn't a threat to society.
D. The client is malingering.
91. A client is admitted with dehydration due to nausea, vomiting, and diarrhea as a result of food poisoning. The client is to receive 2,000 ml of normal saline in 10 hours. After the I.V. fluids have been absorbed, which of the following would indicate that the client's level of hydration has improved?
A. Lower hematocrit (HCT)
B. Lower white blood cell (WBC) count
C. Lower creatinine
D. No further weight loss
92. Before a transesophageal echocardiogram, a client is given an oral topical anesthetic spray. Upon return from the procedure, the nurse observes that the client has no active gag reflex. In response, the nurse should:
A. insert an oral airway.
B. withhold food and fluids.
C. position the client on his side.
D. introduce a nasogastric (NG) tube.
93. When assessing a client with pleural effusion, the nurse should expect to find:
A. Moist crackles at the posterior of the lungs
B. Deviation of the trachea toward the involved side
C. Reduced or absent breath sounds at the base of the lung
D. Increased resonance with percussion of the involved area
94. Nerve injury can occur as a result of the trauma associated with a thyroidectomy. When assessing for this complication, the nurse should evaluate the client's ability to:
A. Speak
B. Swallow
C. Purse the lips
D. Turn the head
95. Which of the following clients would qualify for hospice care?
A. A client with late-stage acquired immunodeficiency syndrome (AIDS)
B. A client with left-side paralysis after a cerebrovascular accident
C. A client who is undergoing treatment for heroin addiction
D. A client who had coronary artery bypass surgery 2 weeks ago
96. The nurse is about to administer a medication to a client with whom the nurse is unfamiliar. To verify the client's identity, the nurse should:
A. ask the client his name.
B. check the name posted outside the client's room.
C. ask a family member the identity of the client.
D. check the client's identification bracelet.
97. A client has a tentative diagnosis of primary biliary cirrhosis. Symptoms include jaundice, ascites, and peripheral edema. When performing the physical assessment, the nurse would expect to observe the skin change known as:
A. Vitiligo
B. Hirsutism
C. Melenosis
D. Telangiectasis
98. The nurse, aware of a client's 25-year history of excessive alcohol use, would expect the physical assessment to reveal a:
A. Liver infection
B. Low blood ammonia
C. Small liver with a rough surface
D. High fever with a generalized rash
99. Which of the following nursing actions would be most appropriate immediately after nasogastric tube removal?
A. Provide the client with mouth care.
B. Auscultate for bowel sounds.
C. Palpate for abdominal distention.
D. Provide orange sherbet.
100.When preparing a client with a draining vertical incision for ambulation, where should the nurse apply the thickest portion of a dressing?
A. At the top of the wound
B. In the middle of the wound
C. At the base of the wound
D. Over the total wound
ANSWERS
1. D
2. D
3. D
4. A
5. D
6. A
7. A
8. B
9. D
10. B
11. B
12. B
13. A
14. C
15. D
16. D
17. B
18. A
19. C
20. B
21. D
22. B
23. D
24. D
25. D
26. A
27. B
28. A
29. B
30. D
31. B
32. C
33. A
34. A
35. B
36. D
37. B
38. B
39. D
40. A
41. B
42. A
43. A
44. D
45. A
46. A
47. B
48. B
49. A
50. C
51. D
52. A
53. B
54. C
55. D
56. B
57. A
58. C
59. A
60. C
61. C
62. A
63. C
64. D
65. B
66. C
67. C
68. B
69. D
70. B
71. C
72. D
73. A
74. A
75. D
76. B
77. A
78. C
79. A
80. A
81. D
82. A
83. C
84. A
85. A
86. D
87. C
88. C
89. A
90. A
91. AB
92. B
93. C
94. A
95. A
96. D
97. D
98. C
99. A
100. C
QUESTIONS AND ANSWERS
1. When assessing a 13-month-old infant with dehydration and metabolic acidosis, the nurse should expect to see which clinical manifestation?
A. Reduced white blood cell count
B. Reduced platelet count
C. Shallow respirations
D. Tachypnea
2. During the insertion of a rigid scope for bronchoscopy, a client experiences a vasovagal response. The nurse should expect:
A. the client's pupils to become dilated.
B. the client to experience bronchodilation.
C. a decrease in the client's gastric secretions.
D. a drop in the client's heart rate.
3. A client who has a potassium level of 6 mEq/L should be treated with:
A. antacids.
B. I.V. fluids.
C. fluid restriction.
D. sodium polystyrene sulfonate (Kayexalate).
4. The occupational health nurse is screening employees for symptoms of carpal tunnel syndrome. Symptoms indicative of carpal tunnel syndrome most commonly include:
A. Paresthesia in the thumb and first and second fingers.
B. Difficulty flexing fingers.
C. Decreased capillary refilling.
D. Numbness in the forearm.
5. A 72-year-old man is admitted to the hospital complaining of right-sided weakness and difficulty speaking. The patient tells the nurse that he fell while at home. It would be MOST important for the nurse's initial assessment of the patient to include evaluation for
A. nutritional deficiencies.
B. ambulation problems.
C. hearing difficulties.
D. head injury.
6. The nurse must obtain a urine specimen from an infant. The nurse can best obtain a clean-catch specimen by:
A. applying a pediatric urine collector to dry skin.
B. placing the infant on a pediatric bedpan.
C. inserting an indwelling urinary catheter.
D. wringing out a cloth diaper after the infant voids.
7. A 3-month-old with meningococcal meningitis has just been admitted to the pediatric unit. Which nursing intervention has the highest priority?
A. Instituting droplet precautions
B. Administering acetaminophen (Tylenol)
C. Obtaining history information from the parents
D. Orienting the parents to the pediatric unit
8. A client appears very anxious, with respirations that are shallow and very rapid (40 per minute). The client complains of feeling dizzy and light-headed and of having tingling sensations of the fingertips and around the lips. The nurse should recognize that the client's complaints are probably related to:
A. Eupnea
B. Hyperventilation
C. Kussmaul's respirations
D. Carbon dioxide intoxication
9. The nurse performs an assessment of a newborn boy. Which of the following observations, by the nurse, would be considered an ABNORMAL finding in a newborn?
A. He breathes 40 times per minute with short periods of apnea.
B. His heart rate is 140 beats per minute with variation during sleeping and waking states.
C. A sudden loud noise causes abduction of his arms and flexion of his elbows.
D. Stroking the outer sole of his foot upwards causes his toes to curl downward.
10. A Foley catheter operates by the principle of:
A. Inertia
B. Gravity
C. Diffusion
D. Osmosis
11. On the first day following a right pneumonectomy a male client suddenly sits straight up in bed. His respirations are labored, and he is making a crowing sound. His skin is pale, cool, and moist. Immediately the nurse should:
A. Notify the physician
B. Auscultate the left lung
C. Inspect the incision for bleeding
D. Check the chest tube for patency
12. A school-age child has a fever, joint inflammation, and a nonpruritic rash. Knowing that these are signs of rheumatic fever, the nurse should ask the parents:
A. "Has your child recently been exposed to other children with rheumatic fever?"
B. "Has your child had strep throat recently?"
C. "Does your child have a congenital heart defect?"
D. "Is your child's Haemophilus influenzae vaccine up-to-date?"
13. An adolescent has an order for placement of a pulse oximeter. To ensure accuracy of the pulse oximeter reading, the nurse should:
A. Place the probe on a finger or earlobe
B. Calibrate the oximeter at least every 8 hours
C. Place the probe on the abdomen or upper leg
D. After application wait 30 minutes before obtaining a reading
14. Surgery is performed on a client with a parotid tumor. The postoperative arterial blood gas values are pH 7.32; PCO2 53 mm Hg; HCO3 25 mEq/L. The nurse should:
A. Obtain a medical order for the administration of a diuretic
B. Have the client breathe into a rebreather bag at a slow rate
C. Encourage the client to cough productively and take deep breaths
D. Obtain a medical order for the administration of sodium bicarbonate
15. Which of the following would be least likely to affect the parent-child relationship?
A. Readiness for the pregnancy
B. Nature of the pregnancy
C. Maturity of the parents
D. Grandparent support
16. Which intervention provides the most accurate information about an infant's hydration status?
A. Monitoring the infant's vital signs
B. Accurately measuring intake and output
C. Monitoring serum electrolytes
D. Weighing the infant daily
17. An infant is diagnosed with a congenital hip dislocation. On assessment, the nurse expects to note:
A. symmetrical thigh and gluteal folds.
B. Ortolani's sign.
C. increased hip abduction.
D. femoral lengthening.
18. Which of the following temperament attributes is best defined as the regularity in the timing of physiologic functions?
A. Rhythmicity
B. Approach--withdrawal
C. Adaptability
D. Intensity of reaction
19. The American Cancer Society (ACS) recommends routine screening to detect colorectal cancer. Which screening test for colorectal cancer should the nurse recommend?
A. Carcinoembryonic antigen (CEA) test after age 50
B. Proctosigmoidoscopy after age 30
C. Annual digital examination after age 40
D. Barium enema after age 20
20. The nurse is conducting a mental status examination on a client with a cognitive disorder. Which of the following statements does the nurse judge to be an impairment in abstract thinking? The client's:
A. Ability to remember her wedding day.
B. Inability to find a similarity between a bird and a butterfly.
C. Memories regarding her vacation 5 years ago.
D. Inability to state her home address.
21. To which of the following nursing diagnoses would a nurse give priority when caring for a patient who is not eating or bathing and refuses to leave the house since the death of her daughter a year ago?
A. Anxiety related to fear of death
B. Self-care deficit related to loss
C. Anticipatory grieving related to fear of social interaction
D. Dysfunctional grieving related to loss
22. A client's monitor shows a PQRST wave for each beat and indicates a rate of 120. The rhythm is regular. The nurse should note that the client is experiencing:
A. Atrial fibrillation
B. Sinus tachycardia
C. Ventricular fibrillation
D. First-degree atrioventricular block
23. When educating the client with adult-onset diabetes mellitus about activity level, the nurse bases the information on the knowledge that exercise affects the body's physiologic functioning relative to glucose usage in which of the following ways?
A. Exercise helps avoid hypoglycemia.
B. Exercise stimulates insulin overproduction.
C. Exercise decreases the renal threshold for glucose.
D. Exercise increases the use of glucose by muscles.
24. When performing a neurologic assessment on a client, the nurse finds that the client's pupils are fixed and dilated. What does this assessment of the client's eyes indicate?
A. The client is permanently paralyzed.
B. The client is going to be blind as a result of an injury.
C. The client probably has meningitis.
D. The client has received a significant brain injury.
25. Which of the following clinical manifestations would be most indicative of complete arterial obstruction in the lower extremities?
A. Aching pain.
B. Burning sensations.
C. Numbness and tingling.
D. Coldness.
26. Which of the following techniques would the nurse use first to determine if a nasogastric tube is positioned in the stomach?
A. Aspirating with a syringe and observing for the return of gastric contents.
B. Irrigating with normal saline and observing for the return of solution.
C. Placing the tube's free end in water and observing for air bubbles.
D. Instilling air and auscultating over the epigastric area for the presence of the tube.
27. To help control pain during coughing for a client who has had a lobectomy, the nurse should:
A. Place the bed in slight Trendelenburg's position and help the client turn onto her operative side to splint the incision.
B. Raise the bed to semi-Fowler's position and place one hand on the client's back, on the left side, and one hand under the incision.
C. Keep the bed flat and tell the client to place her hands over the incision before taking a deep breath.
D. Raise the bed to complete Fowler's position and help the client turn onto her operative side to splint the incision.
28. When monitoring a child for respiratory distress, which of the following would be the earliest sign to report?
A. Restlessness
B. Cyanosis
C. Dyspnea
D. Fever
29. Clients with diabetes mellitus require frequent vision assessment. The nurse should instruct the client about which of the following eye problems most likely to be associated with diabetes mellitus?
A. Cataracts.
B. Retinopathy.
C. Astigmatism.
D. Glaucoma.
30. When assessing a client with cellulitis of the right leg, which of the following would the nurse expect to find?
A. Painful skin that is swollen and pale in color
B. Cold, red skin
C. Small, localized blackened area of skin
D. Red, swollen skin with inflammation spreading to surrounding tissues
31. A child, recently returned from a camping trip, complains of a rash, chills, fever, and a headache and is taken to the clinic by the parents. The nurse in the clinic recognizes that this child's history and physical assessment should include:
A. A history of allergies and duration of symptoms
B. A developmental screening and history of exposure to chickenpox
C. Sports played on the trip and when the child has to return to school
D. The date the child received a flu vaccination and a history of any sunburn
32. Which of the following assessment findings would the nurse observe first in a patient who is undergoing peritoneal dialysis and is developing peritonitis?
A. Dialysate leakage at catheter site
B. Insufficient flow of dialysate
C. Cloudy dialysate returns
D. Increased dialysate returns
33. After gathering all necessary equipment and setting up the supplies, which of the following would be the first step in performing endotracheal (ET) or tracheal suctioning in an infant?
A. Provide extra oxygen by using a ventilator or through manual bagging.
B. Insert a suction catheter to the appropriate measured length.
C. Insert a few drops of sterile saline solution.
D. Put on clean gloves.
34. Which of the following measures would be most helpful for the infant with gastroesophageal reflux?
A. Thickening the formula
B. Less frequent burping
C. Using smaller nipple holes
D. Positioning supine after feeding
35. The nurse is changing a client's dressing. Which observation of the wound warrants immediate physician notification?
A. Approximated wound edges
B. Yellow, purulent drainage
C. Suture in place
D. Pink granulation tissue
36. To assess the client's dorsalis pedis pulse, the nurse should palpate the:
A. Medial surface of the ankle.
B. Lateral surface of the ankle.
C. Ventral aspect of the top of the foot.
D. Medial aspect of the dorsum of the foot.
37. Which of the following activities should the nurse encourage the client with a peptic ulcer to avoid?
A. Chewing gum.
B. Smoking cigarettes.
C. Eating chocolate.
D. Taking acetaminophen (Tylenol).
38. When caring for a client with a 3-cm stage 1 pressure ulcer on the coccyx, which of the following actions can the nurse institute independently?
A. Using a povidone-iodine wash on the ulceration three times per day
B. Using a normal saline solution and applying a protective dressing as necessary
C. Applying an antibiotic cream to the area three times per day
D. Massaging the area with an astringent every 2 hours
39. A client returns from a myelogram, for which an iodized oil (Pantopaque) was used. Which one of the following nursing measures would be included in his care?
A. Bed rest with bathroom privileges.
B. Restricted fluid intake.
C. Head of the bed elevated 45 degrees.
D. Assessment of lower extremity movement and sensation.
40. When obtaining a tympanic temperature in a 2-year-old, in which of the following directions would the nurse pull on the earlobe to straighten the ear canal?
A. Down and back
B. Up and forward
C. Back and up
D. Forward and down
41. A 5-month-old infant is brought to the clinic by the mother who reports that he has nasal congestion, symptoms of a cold, fever, and difficulty breathing. The nurse should first:
A. ask for more history information.
B. perform a respiratory assessment.
C. notify the available physician.
D. take vital signs, including temperature.
42. A 13-year-old may have appendicitis. Which of the following symptoms would help determine the child's condition?
A. The severity, location, and movement of pain
B. The degree of fever
C. A history of vomiting and diarrhea, if present
D. A history of irritability and lethargy
43. When assessing a 7-month-old, which of the following reflexes would the nurse expect to be present?
A. Plantar grasp
B. Palmar grasp
C. Tonic neck
D. Moro
44. To locate the point of maximum impulse (PMI) of a patient's heart, the nurse's hand (fingertips) should be placed over which of the following locations?
A. The fifth intercostal space directly over the sternum.
B. The second intercostal space to the right of the sternum.
C. The second intercostal space to the left of the sternum.
D. The fifth intercostal space at the midclavicular line.
45. A 16-year-old who is depressed cheers up and gives her teddy bear to her favorite nurse. Which of the following is the priority for the nurse at this time?
A. Assess the adolescent for possible suicidal ideation
B. Tell her mother to call for a psychiatric referral
C. Give the bear back and discuss transitional objects
D. Praise her mood change and her passage from childhood
46. Pain control is an important nursing goal for the client with pancreatitis. Which of the following medications would the nurse plan to administer in this situation?
A. Meperidine hydrochloride (Demerol).
B. Cimetidine (Tagamet).
C. Morphine sulfate.
D. Codeine sulfate.
47. A client is at risk for developing a pressure ulcer. The first warning of an impending pressure ulcer is when pressure applied to skin turns it:
A. Bluish.
B. Reddish.
C. Whitish.
D. Yellowish.
48. The nurse is assessing a client with heart failure. The breath sounds commonly auscultated in clients with heart failure are:
A. tracheal.
B. fine crackles.
C. coarse crackles.
D. friction rubs.
49. A client with fever, weight loss, and watery diarrhea is being admitted to the health care facility. While assessing the client, a nurse inspects the client's abdomen and notices that it's scaphoid. Additional assessment should proceed in which order?
A. Auscultation, percussion, and palpation
B. Palpation, percussion, and auscultation
C. Percussion, palpation, and auscultation
D. Palpation, auscultation, and percussion
50. As part of the annual health screening, the nurse visits the eighth-grade physical education classes and asks each student to bend forward at the waist with the back parallel to the floor and the hands together at midline. For which of the following is the nurse assessing?
A. Slipped epiphysis.
B. Developmental dysplasia of hip.
C. Idiopathic scoliosis.
D. Physical dexterity.
51. A client receives meperidine (Demerol) 50 mg I.M. for relief of surgical pain. Thirty minutes later, the nurse asks the client if the pain is relieved. Which step of the nursing process is the nurse using?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
52. Which of the following statements, if voiced by the parents of a female child receiving cotrimoxazole (Septra/Bactrim) for a urinary tract infection, would indicate the need for additional teaching?
A. "We'll make arrangements to have her WBC count checked routinely."
B. "We'll continue to give her the medication until the drug is finished."
C. "We'll try to make sure that she doesn't go outside in the sun."
D. "We'll call the physician immediately if a rash occurs."
53. A client has emergency surgery for a ruptured appendix. After assessing that the client is manifesting symptoms of shock the nurse should:
A. Prepare for a blood transfusion
B. Notify the physician immediately
C. Elevate the head of the bed 30 degrees
D. Administer the oxygen prescribed postoperatively
54. The nurse is about to give an I.M. injection to a 2-year-old child. Which site should be avoided?
A. Vastus lateralis muscle
B. Ventrogluteal muscle
C. Dorsogluteal muscle
D. Deltoid muscle
55. During the insertion of a nasogastric tube, the nurse would evaluate that the client was experiencing difficulty if the client demonstrated:
A. Choking
B. Flushing
C. Gagging
D. Cyanosis
56. The client underwent a bowel resection and was in the post-anesthesia recovery unit for 1 hour. She returns from the recovery room with an intravenous line, a nasogastric tube, and a Foley catheter in place. She complains of pain and asks for medication. What action should the nurse take first?
A. Administer the ordered narcotic.
B. Establish the location and severity of pain.
C. Determine if she was medicated for pain in the post-anesthesia recovery unit.
D. Reposition her and give her a back rub.
57. A client is diagnosed as having a peptic ulcer. The nurse would expect that the client's pain:
A. Occurs 1 to 3 hours after meals
B. Is intensified when vomiting occurs
C. Increases when fatty foods are ingested
D. Begins in the epigastrium and radiates to the abdomen
58. A 3-month-old infant just had a cleft lip and palate repair. To prevent trauma to the operative site, the nurse should do which of the following?
A. Give the baby a pacifier to help soothe him.
B. Lie the baby in the prone position.
C. Place the infant's arms in soft elbow restraints.
D. Avoid touching the suture line, even to clean.
59. When assessing the child with an acute asthmatic attack, which of the following would the nurse expect to find?
A. Hyperresonance on chest percussion
B. Increased oxygen saturation
C. Inspiration longer than expiration
D. Elevated forced vital capacity
60. Which of the following techniques enhances breath sound auscultation?
A. Warming the stethoscope
B. Wetting the stethoscope
C. Listening with the diaphragm
D. Listening with the bell
61. Following a gastrojejunostomy (Billroth II) for cancer of the stomach, a client progresses to a regular diet. After eating lunch the client becomes diaphoretic and has palpitations. The symptoms are probably the result of:
A. An intolerance to fatty foods
B. The dehiscence of the surgical incision
C. An extracellular fluid shift into the bowel
D. Diminished peristalsis in the small intestine
62. Which of the following chloride levels on a sweat test would confirm the diagnosis of cystic fibrosis?
A. Greater than 60 mEq/L
B. 20 mEq/L or slightly less
C. 20 to 30 mEq/L
D. 50 to 60 mEq/L
63. When performing an admission assessment on a newly admitted client, the nurse percusses resonance. The nurse knows that resonance heard on percussion is most commonly heard over which organ?
A. Heart
B. Liver
C. Lung
D. Spleen
64. Which intervention takes priority when admitting an infant with acute gastroenteritis?
A. Obtaining a stool specimen
B. Weighing the infant
C. Offering the infant clear liquids
D. Obtaining a history of the illness
65. For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These assessments indicate which nursing diagnosis?
A. Impaired urinary elimination
B. Deficient fluid volume
C. Imbalanced nutrition: Less than body requirements
D. Excessive fluid volume
66. The parents of an adolescent girl have recently learned that their daughter has a terminal illness. At first, as they try to cope, they display avoidance behaviors. Then they demonstrate behaviors that indicate possible acceptance of the diagnosis. Which behavior would indicate acceptance?
A. Failure to recognize the seriousness of the child's condition despite physical evidence
B. Intellectualization about the illness in areas unrelated to the child's condition
C. Expression of feelings, such as sorrow and anger, about the child's condition
D. Avoidance of staff, family members, or the child
67. An arterial blood gas (ABG) is ordered for a 46-year-old man following a myocardial infarction. After obtaining the ABG, which of the following measures would be ESSENTIAL for the nurse to implement?
A. Obtain ice for the specimen.
B. Apply a sterile dressing to the site.
C. Apply direct pressure to the site.
D. Observe the site for hematoma formation.
68. Which electrolyte imbalance would a nurse expect when assessing a patient with bulimia?
A. Hyperkalemia
B. Hypokalemia
C. Hypercalcemia
D. Hypocalcemia
69. A 5-year-old child is being admitted to same-day surgery for a tonsillectomy and adenoidectomy. The nurse should assess for which of the following when admitting a client for this particular procedure?
A. Nasal abnormalities
B. Recent exposure to any communicable disease
C. Immunization history
D. The presence of any loose teeth
70. When teaching a client with peripheral vascular disease about foot care, the nurse should include which instruction?
A. Avoid using cornstarch on the feet.
B. Avoid wearing canvas shoes.
C. Avoid using a nail clipper to cut toenails.
D. Avoid wearing cotton socks.
71. Before administering a tube feeding to a toddler, which of the following methods should the nurse use to check the placement of a nasogastric (NG) tube?
A. Abdominal X-rays
B. Injection of a small amount of air while listening with a stethoscope over the abdominal area
C. A check of the pH of fluid aspirated from the tube
D. Visualization of the measurement mark on the tube made at the time of insertion
72. A 65-year-old woman is recovering from a right below-the-knee amputation. The patient observes the "figure eight" bandage on her residual limb. She asks the nurse why the bandage is applied in this manner. Which of the following explanations, if made by the nurse, is MOST accurate?
A. "It decreases the possibility of infection."
B. "It helps to minimize postoperative pain."
C. "It reduces the possibility of clot formation."
D. "It reduces postoperative swelling."
73. A client diagnosed with a peptic ulcer undergoes an upper gastrointestinal endoscopy to help the physician visualize the ulcer's location and severity. Immediately after the endoscopy, what would be a priority for the nurse to assess?
A. Return of the gag reflex.
B. Bowel sounds.
C. Peripheral pulses.
D. Intake and output.
74. Which signs and symptoms suggest that a client's abdominal aortic aneurysm is extending?
A. Increased abdominal and back pain
B. Decreased pulse rate and blood pressure
C. Retrosternal back pain radiating to the left arm
D. Elevated blood pressure and rapid respirations
75. When preparing the client with hepatitis A for extended convalescence, the nurse teaches the client about problems that may occur. The nurse knows that the client has understood the teaching when he says that he is most likely to have difficulty:
A. Controlling abdominal pain.
B. Maintaining a regular bowel elimination pattern.
C. Preventing respiratory complications.
D. Maintaining a positive, optimistic outlook.
76. The nurse is performing an assessment on a client who has developed a paralytic ileus. The client's bowel sounds will be:
A. hyperactive.
B. hypoactive.
C. high-pitched.
D. blowing.
77. Which of the following would lead the nurse to suspect increasing intracranial pressure in an infant in the earlier stages?
A. Tense bulging fontanel
B. Decreased pupil size
C. Low pitched cry
D. Vomiting
78. Which nursing measure would be most effective in helping the client cough and deep breathe after a cholecystectomy?
A. Having the client take rapid, shallow breaths to decrease pain.
B. Having the client lay on the left side while coughing and deep breathing.
C. Teaching the client to use a folded blanket or pillow to splint the incision.
D. Withholding pain medication so the client can be alert enough to follow the nurse's instructions.
79. Which of the following assessment findings would be exhibited in a child with Cushing syndrome?
A. Increased susceptibility to infection and virilization
B. Decreased appetite and paleness
C. Decreased blood pressure and acidosis
D. Hypoglycemia and skin thickening
80. When caring for the pregnant adolescent, which of the following is the primary goal?
A. Obtaining prenatal care
B. Promoting nutrition
C. Understanding body changes
D. Preventing secondary pregnancy
81. The correct procedure for auscultating the client's abdomen for bowel sounds would include:
A. Palpating the abdomen first to determine correct stethoscope placement.
B. Encouraging the client to cough to stimulate movement of fluid and air through the abdomen.
C. Placing the client on the left side to aid auscultation.
D. Listening for 5 minutes in all four quadrants to confirm absence of bowel sounds.
82. During auscultation of the heart, the nurse would expect the first heart sound (S1) to be the loudest at the:
A. Apex of the heart
B. Base of the heart
C. Left lateral border
D. Right lateral border
83. While assessing the incision of a client who had surgery 2 weeks ago, the nurse observes that the suture line has a shiny, light pink appearance. Which of the following steps would the nurse take next?
A. Notify the physician because the wound may be dehiscing.
B. Apply normal saline solution to keep the wound moist.
C. Do nothing because this is granulation tissue.
D. Prepare the client for debridement of the suture line.
84. Which of the following explanations would be included when teaching the parents of a child with autosomal recessive disorder?
A. There is a 25% chance of child being affected
B. The disorder usually affects male children
C. There are no carriers, only affected persons
D. Only one of the parents is affected
85. A 23-month-old child is brought to the emergency department with suspected croup. Which assessment finding reflects increasing respiratory distress?
A. Intercostal retractions
B. Bradycardia
C. Decreased level of consciousness
D. Flushed skin
86. 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?
A. "The pain associated with a heart attack is much more severe."
B. "The pain associated with a heart attack radiates into the jaw and down the left arm."
C. "It is impossible to differentiate anginal pain from that of a heart attack without an ECG."
D. "The pain of angina is usually relieved by resting or lying down."
87. An infant has undergone surgery to remove a myelomeningocele. To detect increased intracranial pressure (ICP) as early as possible, the nurse should be alert for which of the following postoperative findings?
A. Decreased urine output
B. Increased heart rate
C. Bulging fontanels
D. Sunken eyeballs
88. Which of the following assessments would be most supportive of the nursing diagnosis, Impaired skin integrity related to purulent wound drainage?
A. Heart rate of 88 beats/minute
B. Wound healing by first intention
C. Oral temperature of 101
89. To test a school-ager's sense of conservation, which of the following would the nurse do?
A. Show two equal-length pencils side by side, then move them out of alignment to see if the child realizes they are still the same length.
B. Give child a group of numbered blocks and have child arrange them according to some ordinal scale.
C. Give child a mixture of stamps, wrappers, and shells and have child group them according to some classification system.
D. State a situation to the child, then have the child anticipate the consequences and rethink the action in a different direction.
90. The nurse is caring for a client who was found huddled in her apartment by the police. The client stares toward one corner of the room and seems to be responding to something not visible to others. She appears hyperalert and scared. How would the nurse assess the situation?
A. The client may be hallucinating.
B. The client is suicidal.
C. Nothing is wrong because the client isn't a threat to society.
D. The client is malingering.
91. A client is admitted with dehydration due to nausea, vomiting, and diarrhea as a result of food poisoning. The client is to receive 2,000 ml of normal saline in 10 hours. After the I.V. fluids have been absorbed, which of the following would indicate that the client's level of hydration has improved?
A. Lower hematocrit (HCT)
B. Lower white blood cell (WBC) count
C. Lower creatinine
D. No further weight loss
92. Before a transesophageal echocardiogram, a client is given an oral topical anesthetic spray. Upon return from the procedure, the nurse observes that the client has no active gag reflex. In response, the nurse should:
A. insert an oral airway.
B. withhold food and fluids.
C. position the client on his side.
D. introduce a nasogastric (NG) tube.
93. When assessing a client with pleural effusion, the nurse should expect to find:
A. Moist crackles at the posterior of the lungs
B. Deviation of the trachea toward the involved side
C. Reduced or absent breath sounds at the base of the lung
D. Increased resonance with percussion of the involved area
94. Nerve injury can occur as a result of the trauma associated with a thyroidectomy. When assessing for this complication, the nurse should evaluate the client's ability to:
A. Speak
B. Swallow
C. Purse the lips
D. Turn the head
95. Which of the following clients would qualify for hospice care?
A. A client with late-stage acquired immunodeficiency syndrome (AIDS)
B. A client with left-side paralysis after a cerebrovascular accident
C. A client who is undergoing treatment for heroin addiction
D. A client who had coronary artery bypass surgery 2 weeks ago
96. The nurse is about to administer a medication to a client with whom the nurse is unfamiliar. To verify the client's identity, the nurse should:
A. ask the client his name.
B. check the name posted outside the client's room.
C. ask a family member the identity of the client.
D. check the client's identification bracelet.
97. A client has a tentative diagnosis of primary biliary cirrhosis. Symptoms include jaundice, ascites, and peripheral edema. When performing the physical assessment, the nurse would expect to observe the skin change known as:
A. Vitiligo
B. Hirsutism
C. Melenosis
D. Telangiectasis
98. The nurse, aware of a client's 25-year history of excessive alcohol use, would expect the physical assessment to reveal a:
A. Liver infection
B. Low blood ammonia
C. Small liver with a rough surface
D. High fever with a generalized rash
99. Which of the following nursing actions would be most appropriate immediately after nasogastric tube removal?
A. Provide the client with mouth care.
B. Auscultate for bowel sounds.
C. Palpate for abdominal distention.
D. Provide orange sherbet.
100.When preparing a client with a draining vertical incision for ambulation, where should the nurse apply the thickest portion of a dressing?
A. At the top of the wound
B. In the middle of the wound
C. At the base of the wound
D. Over the total wound
ANSWERS
1. D
2. D
3. D
4. A
5. D
6. A
7. A
8. B
9. D
10. B
11. B
12. B
13. A
14. C
15. D
16. D
17. B
18. A
19. C
20. B
21. D
22. B
23. D
24. D
25. D
26. A
27. B
28. A
29. B
30. D
31. B
32. C
33. A
34. A
35. B
36. D
37. B
38. B
39. D
40. A
41. B
42. A
43. A
44. D
45. A
46. A
47. B
48. B
49. A
50. C
51. D
52. A
53. B
54. C
55. D
56. B
57. A
58. C
59. A
60. C
61. C
62. A
63. C
64. D
65. B
66. C
67. C
68. B
69. D
70. B
71. C
72. D
73. A
74. A
75. D
76. B
77. A
78. C
79. A
80. A
81. D
82. A
83. C
84. A
85. A
86. D
87. C
88. C
89. A
90. A
91. AB
92. B
93. C
94. A
95. A
96. D
97. D
98. C
99. A
100. C
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