1. The Nurse Would Evaluate That The Client Understands His

1. The nurse would evaluate that the client understands his home care instructions after scleral buckling for a detached retina if he says his activity should include: a. Avoiding abrupt movements of the head b. Exercising the eye muscles each day c. Turning the entire head rather than just the eyes for sight d. Avoiding activities requiring good depth perception 2. Lomotil has been prescribed to treat a client’s diarrhea. The nurse should teach the client to report which of the following common side effects? a. Urinary retention b. Diaphoresis c. Hypotension d. Lethargy 3. Nitroglycerin is also available in ointment or paste form. Before applying nitroglycerin ointment, the nurse should: a. Cleanse the skin with alcohol where the ointment will be placed. b. Obtain the client’s pulse rate and rhythm c. Remove the ointment previously applied d. Instruct the client to expect pain relief in the next 15 minutes 4. While a client with hypertension is being assessed, he says to the nurse, “I really don’t know why I am 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 5. For a neurologically injured client, the nurse would best assess motor strength by: a. Comparing equality of hand grasps b. Observing spontaneous movements c. Observing the client feed himself d. Asking him to signal if he feels pressure applied to his feet

6. Morphine 8 mg IM has been ordered for a client. The ampule label reads 15 mg/mL. How many milliliters will the nurse give? a. 0.45 mL b. 0.53 mL c. 0.66 mL d. 0.75 mL 7. 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 5minutes in all four quadrants to confirm absence of bowel sound 8. A client is admitted to the hospital with a diagnosis of a right hip fracture. She complains of right hip pain and cannot move her right leg. Which of the following assessments made by the nurse indicates that the client has a typical sign of hip fracture? The client’s right leg is: a. Rotated internally b. Held in a flexed position c. Adducted d. Shorter than the leg on the unaffected side 9. The nurse assesses the client’s understanding of the relationship between body position and gastroesophageal reflux. Which response would indicate that the client understands measures to avoid problems with reflux while sleeping? a. I can elevate the foot of the bed 4 to 6 inches b. I can sleep on my stomach with my head turned to the left c. I can sleep on my back without a pillow under my head d. I can elevate the head of the bed 4 to 6 inches 10. Which of the following would be an appropriate nursing diagnosis for a hospitalized client with bacterial pneumonia and shortness of breath? a. Ineffective cardiopulmonary tissue perfusion related to myocardial damage b. Risk for self-care deficit related to fatigue c. Deficient fluid volume related to nausea and vomiting

d. Disturbed thought processes related to inadequate relief of chest pain 11. Theophylline ethylenediamide is administered to a client with COPD to: a. Reduce bronchial secretions b. Relax bronchial smooth muscle c. Strengthen myocardial contractions d. Decrease alveolar elasticity 12. Which of the following lab results would be unexpected in a client with chronic renal failure? a. Serum potassium 6.0 mEq/L b. Serum creatinine 9 mg/dL c. BUN 15 mg/dL d. Serum phosphate 5.2 mg/dL.

13. Which of the following criteria are acceptable for a rescuer to discontinue CPR? a. When it is obvious that the victim will not survive b. When the rescuer is exhausted c. After 30 minutes of CPR without a pulse rate d. When the family requests discontinuation 14. A client is scheduled to undergo an abdominal perineal resection with a permanent colostomy. Which of the following measures would be an anticipated part of the client’s preoperative care? a. Keep the client NPO for 24 hrs before surgery b. Administer neomycin sulfate the evening before surgery c. Inform the client that total parenteral nutrition will likely be implemented after surgery d. Advise the client to limit physical activity 15. The nurse notes that the client’s urinary appliance contains yellow urine with large amounts of mucus. How would the nurse best interpret these data? a. The client is developing an infection of the urinary tract b. The mucus is caused by elevated levels of glucose in the urine c. These findings are normal for a client with an ileal conduit d. There is irritation of the stoma

16. 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 17. A client with iron-deficiency anemia is prescribed liquid iron supplements. The nurse evaluates the client’s understanding of how to take this drug. Which of the following statements indicates the client has adequate knowledge? a. I can use antidiarrheal drugs if I develop diarrhea b. I will report any black stools to the physician c. I will check my gums for any bleeding d. I will dilute the medication and drink it with a straw 18. The nurse has instructed the client about the correct positioning of his leg and hip following hip replacement surgery. Which of the following statements indicate that the client has understood these instructions? a. I may cross my legs as long as I keep my knees extended b. I should avoid bending over to tie my shoes c. I can sit in any chair that I find comfortable d. I should avoid any unnecessary walking for about 3 months after my surgery 19. 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 20. An autograft is taken from the client’s left leg. The nurse should care for the donor site by: a. Covering it with an occlusive dry dressing b. Keeping the site clean and dry c. Applying a pressure dressing d. Wrapping the extremity with an elastic bandage

21. Which of the following categories of medications would the nurse anticipate being included in the conservative management of a client with a herniated lumbar disk? a. Muscle relaxant b. Sedatives c. Tranquilizers d. Parenteral analgesics 22. The client has a nursing diagnosis of Constipation related to decreased mobility secondary to traction. A care plan that incorporates which of the following breakfasts would be most helpful in reestablishing a normal bowel routine? a. Eggs and bacon, buttered white toast, orange juice and coffee b. Corn flakes with sliced banana, milk and English muffin with jelly c. Orange juice, breakfast pastries (doughnut and Danish) and coffee d. An orange, raisin bran and milk, and wheat toast with butter 23. A client has been placed on levodopa to treat Parkinson’s disease. Which of the following is a common side effects of levodopa that the nurse should include in the client’s teaching plan? a. Pancytopenia b. Peptic ulcer c. Postural hypotension d. Weight loss 24. The client would be experiencing a typical symptom of Meniere’s disease if, before an attack, he experienced: a. A severe headache b. Blurred vision c. Nausea d. A feeling of inner ear fullness 25. Which of the following observations should the postanesthesia care unit (PACU) nurse plan to make first when the client who has had a modified radical mastectomy returns from the operating room? a. Obtaining and recording vital signs b. Observing that drainage tubes are patent and functioning c. Ensuring that the client’s airway is free of obstruction d. Checking the client’s dressings for drainage

26. The classic signs and symptoms of rheumatoid arthritis include which of the following? a. Pain on weight-bearing, rash and low-grade fever b. Joint swelling, joint stiffness in the morning and bilateral joint movement c. Crepitus, development of Heberden’s nodes and anemia d. Fatigue, leucopenia and joint pain 27. 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 dislodgement. 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 28. A client is scheduled for radical neck surgery and a total laryngectomy. During the preoperative teaching, the nurse should prepare the client for which of the following postoperative possibilities? a. Endotracheal intubation b. Insertion of laryngectomy tube c. Immediate speech therapy d. Gastrostomy tube 29. The client is being taught to self-administer insulin. Learning goals most likely will be attained when they are established by the: a. Nurse and client because both need to be responsible for teaching b. Physician and client because the physician is the manager of care and the client is the main participant c. Client because the client is best able to identify his or her own needs and how to meet those needs d. Client, nurse and physician so the client can participate in planning care with the nurse and physician 30. Which statement by the client with rheumatoid arthritis would indicate that she needs additional teaching to safely receive the maximum benefit of her aspirin therapy? a. I always take aspirin with food to protect my stomach

b. Once I learned to take aspirin with meals, I was able to start using the inexpensive generic brand c. I always watch for bleeding gums or blood in my stool d. I try to take aspirin only on days when the pain seems particularly bad 31. A client has stress incontinence has been given a pamphlet that describes Kegel exercises. Which of the following statements indicates to the nurse that the client has understood the instructions contained in the pamphlet? a. I should perform these exercises every evening b. It will probably take a year before the exercises are effective c. I can do these exercises sitting up, lying down or standing d. I need to tighten my abdominal muscles to do these exercises correctly 32. The development of laryngeal cancer is most clearly linked to which of the following factors? a. High-fat, low-fiber diet b. Alcohol and tobacco use c. Low socioeconomic status d. Overuse of artificial sweeteners 33. Oxtriphylline (Choledyl SA) 0.2 g has been ordered. Available tablets are 100mg. How many tablets should be given? a. 0.5 tablets b. 2.0 tablets c. 2.5 tablets d. 5.0 tablets 34. The most common causes of megaloblastic, macrocytic anemias are: a. Folate or vitamin B deficiency b. Chronic disease c. Iron deficiency d. Infection 35. Which of the following nutrients provides a little over half of the energy needed during sleep? a. Protein b. Carbohydrate c. Fat d. Water

36. An anticipated outcome for the client after cataract removal surgery would include which of the following? a. The client states her vision is clear b. The client states her infection is under control c. The client describes methods to prevent an increase in intraocular pressure d. The client states she is able to administer parenteral pain medication 37. The nurse understands that Hodgkin’s disease is suspected when a client presents with a painless, swollen lymph node. Hodgkin’s disease typically affects people in which age group? a. Children (ages 6-12 years) b. Teenagers (ages 13-20 years) c. Young adults (ages 21-40 years) d. Older adults (ages 41-50 years) 38. The nurse notes the following assessment findings regarding the client’s peripheral vascular status: cramping leg pain relieved by rest; cool, pale feet; and delayed capillary refilling. Based on these data, the nurse would make a nursing diagnosis of: a. Impaired skin integrity b. Impaired gas exchange c. Ineffective peripheral tissue perfusion d. Impaired physical mobility 39. The client with urinary tract infection is given a prescription for trimethoprim (Bactrim-DS) for her infection. Which of the following statements would indicate that she understands the principles of antibiotic therapy? a. I’ll take the pills until I feel better and keep the rest for recurrences b. I’ll take all the pills then return to my doctor c. I’ll take the pills until the symptoms go away then reduce the dose to one pill a day d. I’ll take all the pills then have the prescription renewed once 40. Which of the following clients would the nurse expect to be at highest risk for developing a urinary tract infection? a. Woman who has delivered two children vaginally b. Man with an indwelling urinary catheter for incontinence c. Man with a past medical history of renal calculi

d. Woman with well-controlled diabetes mellitus 41. When bandaging the burned client’s hand, the nurse should make certain that: a. The bandage is free of elastic b. The hand and finger surfaces do not touch c. The hand and fingers are not elevated above heart level d. The bandage material is moistened with sterile normal saline solution 42. The nurse is caring for a client who has a history of aplastic anemia. Which of the following data from the nursing history indicates that the anemia is not being managed effectively? a. Pallor of skin and mucous membranes b. Heart rate of 68 bpm, bounding pulse c. Blood pressure of 146/90 mm Hg d. Poor skin turgor 43. A client is learning about caring for her ileostomy. Which of the following statements would indicate that she understands how to care for her ileostomy pouch? a. I’ll empty my pouch when it’s about one-third full b. I can take my pouch off at night c. I should change my pouch immediately after lunch d. I must apply a new pouch system every day 44. A client’s laboratory tests indicate that the client has hypocalcemia. Which of the following symptoms should the nurse look for in the client? a. Flushed skin b. Depressed reflexes c. Tingling in extremities d. Diarrhea 45. Which of the following symptoms would the nurse most likely observe in a client with cholecystitis from cholelithiasis? a. Black stools b. Nausea after ingestion of high fat foods c. Elevated temperature of 103 F (39.4 C) d. Decreased WBC count 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. b. c. d.

Meperidine hydrochloride (Demerol) Cimetidine (Tagamet) Morphine sulfate Codeine sulfate

47. A client is recovering from a gastric resection for peptic ulcer disease. Which of the following outcomes indicates that the goal of adequate nutritional intake is being achieved 3 weeks following surgery? a. Increases food intake and tolerance gradually b. Experiences occasional episodes of nausea and vomiting c. Drinks 2000 mL/day of water d. Experiences a rapid weight gain within 1 week 48. What would be the most important nursing intervention in caring for the client’s residual limb during the first 24 hrs after amputation of the left leg? a. Keeping the residual limb flat on the bed b. Abducting the residual limb on a scheduled basis c. Applying traction to the residual limb d. Elevating the residual limb on a pillow 49. After the client returns from surgery for a deviated nasal septum, the nurse would anticipate placing her in what position? a. Supine b. Left side-lying c. Semi-Fowler’s d. Reverse Trendelenburg’s 50. While suctioning a client’s laryngectomy tube, the nurse insert the catheter: a. About 1-2 inches b. As the client exhales c. Until resistance is met, then withdraw it 1-2 cm d. Until the client begins coughing