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CD-Rom: Practice Examination #1

CD Rom: Practice Exam 1

CD-Rom: Practice Examination 1 1.

A new mother asks the nurse how often her newborn should breastfeed. Which of the following responses by the nurse would be best?

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A. “As long as the baby feeds four times a day, he will get enough.” B. “Newborns may breastfeed continuously until they stabilize.” C. “Newborns should breastfed at least every 3 hours during the day.” D. “Newborns should be fed when they cry.”

A. “Avoid raw eggs and cats until conception.” B. “Receive immunization against toxoplasmosis.” C. “Begin an iron supplement of 100 mg daily.” D. “Supplement your diet with 400 mcg of folic acid.” 6.

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A nurse teaches a client with asthma how to use an inhaler with a spacer. Which of these client statements would indicate that teaching was ineffective?

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Demerol (meperidine) 50 mg IM Atropine sulfate 0.4 mg IM Valium (diazepam) 2 mg IM Phenergan (promethazine) 25 mg IM 8.

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Encourage fluid intake >1500ml/day. Administer opiate analgesics on schedule. Monitor vital signs for hypertension. Observe for changes in behavior.

When counseling a client who binge eats, the most appropriate approach for the nurse to take is to A. encourage the client to tape a picture of herself on the refrigerator. B. instruct the client to weigh herself daily. C. have the client keep a journal of activities and food intake. D. teach the client to eliminate foods with high calories from her diet.

Which of the following orders should a nurse question for a client with glaucoma who is scheduled for surgery? A. B. C. D.

Which of the following nursing measures would be appropriate in the care of a client who has hepatic encephalopathy? A. B. C. D.

A. “I should inhale before using the inhaler.” B. “I should place my lips firmly around the mouthpiece.” C. “I should hold my breath 8-10 seconds after using the inhaler.” D. “I should wait 1-2 minutes between puffs.” 3.

A client asks the nurse how she can prepare for pregnancy. Which of the following comments by the nurse would be most appropriate?

A 75-year-old male in the emergency department appears frightened and withdrawn. The nurse assesses multiple bruises on his back, abdomen and legs. The best response by the nurse would be

A client is taking the atypical antisychotic medication, olanzapine (Zyprexa). Which of the following client statements indicates that the nurse’s teaching about the side effects of the medication has been successful? A. “I will stand up slowly when getting out of bed.” B. “I will take the medicine on an empty stomach.” C. “I will decrease my fluid intake.” D. “I may have one drink of wine before bed.”

A. “Let me get your son to join us.” B. “Does your family know how you hurt yourself?” C. “You don’t have to tell me what happened.” D. “Let’s go to the conference room and talk.”

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CD Rom: Practice Exam 1 9.

The nurse admits a client with asthma who reports taking all of the following medications. Which medication would the nurse suspect as the possible cause of the asthma attack? A. B. C. D.

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Acetylsalicylic acid (aspirin) Milk of magnesia Pepcid (famotidine) Benadryl (diphenhydramine)

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Apply heating pad to abdomen Obtain X-ray of abdomen Begin an IV of dextrose 5% in water (D5W) Nothing by mouth

In which of the following situations has the nurse violated the client’s right of privacy?

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Blood urea nitrogen of 15 mg/dl Serum albumin level of 3.5 g/dl Blood glucose level of 40 mg/dl Serum creatinine level of 0.6 mg/dl

Which of the following outcomes would indicate the most effective response by a school aged child to asthma medication? A. Ability to participate in active sports for longer periods B. Decrease in allergy skin testing measurements C. Peak expiratory flow rate within normal limits D. Ability to eliminate breathing exercises on weekends and school holidays

16. A hospitalized client with a history of drug abuse is found unresponsive with pinpoint pupils after a visit from a friend. The nurse would expect the client to be treated with which of the following medications? A. B. C. D.

A 70 year old client, diagnosed with type 2 diabetes, has been taking Glucophage (metformin) 500 mg tid. Which of the following laboratory results should the nurse report? A. B. C. D.

A. The nurse informed law enforcement officials about the client’s gunshot wound. B. The nurse turned off the computer after documenting the client’s status. C. The nurse carried unprotected client information in the elevator. D. The nurse reported suspected child abuse to law enforcement officials. 12.

When caring for a client with a femoral venous catheter, it is essential for the nurse to A. irrigate the catheter with sterile saline solution to maintain patency. B. maintain sterile technique when working with the catheter. C. assess the pressure dressing frequently for bleeding. D. limit the mobility of the affected limb.

A 25-year-old client is admitted to the emergency department with a sudden onset of right lower abdominal pain. Which of the following physician orders should the nurse question at this time? A. B. C. D.

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An elderly client displays interest in alternative therapies, such as acupuncture. Which of the following interventions by the nurse would be appropriate? A. Encourage use of more scientifically proven therapies. B. Identify a conventional therapy that can substitute for the alternative one. C. Educate the client about the risk and benefits of the alternative therapy. D. Explain that alternative therapies are not a viable option for older clients.

Dolophine (methadone) Valium (diazepam) Narcan (naloxone) Romazicon (flumazenil)

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CD Rom: Practice Exam 1 17.

A client exhibits coughing, sneezing, dyspnea and wheezing. The nurse administers oxygen therapy to the client. Which of the following outcome measures would the nurse expect to see as a result of the oxygen therapy? A. B. C. D.

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A. “My six year old can exercise with my twelve year old.” B. “The prescribed diabetic diet will be healthy for the whole family.” C. “I will participate in a diabetic education program.” D. “My husband’s family has history of diabetes.”

Improved respiratory rate and rhythm Delayed capillary refill Absence of pain Improved cardiac function

A client with type 2 diabetes complains of nausea, vomiting, diaphoresis and headache. Which of the following nursing interventions should the nurse carry out first?

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A. Withhold the client’s next insulin injection. B. Test the client’s blood glucose level. C. Administer Tylenol (acetaminophen) as ordered. D. Offer fruit juice, gelatin and chicken bouillon. 19.

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pulmonary egophony. amniotic fluid embolism. anaphylaxis. bronchospasm.

The client tells the nurse that she is worried about whether her newborn son will feel pain during circumcision. The most appropriate response by the nurse is A. “Don’t worry, infants don’t have pain receptors.” B. “It is normal for you to experience these concerns.” C. “We are not really sure if the infant cries because of the cold or pain.” D. “We’ll give the baby a pacifier to comfort him.”

In the absence of a signed release by the client, the mental health nurse may share information with A. B. C. D.

The best approach for the mental health nurse to take when a client thinks his food is poisoned is to A. assure the client that all food served on the hospital is safe to eat. B. obtain an order for a tube feeding for the client. C. provide the client with food in unopened containers. D. tell the client that irrational thinking is detrimental to good health.

A woman in labor is receiving an antibiotic. She suddenly complains of trouble breathing, weakness and nausea. The nurse should recognize that these signs are usually indicative of impending A. B. C. D.

The home care nurse recognizes the need to provide further teaching to the mother of a six year old newly diagnosed with diabetes when the mother states

the client’s family. the client’s lawyer. other client’s in the therapeutic group. those involved in the treatment plan.

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A client is admitted for overnight observation following a blow to the head during a baseball game. Which of the following assessments warrants immediate nursing action?

Which of the following nursing interventions would be most important for determining fluid balance in a client with end-stage renal failure? A. B. C. D.

A. Widening pulse pressure and bradycardia B. Narrowing pulse pressure and tachycardia C. Increasing respiration and irregular pulse rate D. Narrowing pulse deficit and decreased level of consciousness

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Monitor urine specific gravity Measure fluid intake and output Weigh daily Record frequency of bowel movements

CD Rom: Practice Exam 1 26.

Which of the following actions would the nurse take first when caring for a mental health client from another country?

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A. Develop a treatment plan based on American standards of mental health. B. Determine the client’s beliefs about mental health. C. Encourage the client to participate in a group with clients from various cultures. D. Involve the client’s family in discharge planning.

A. “I’m not able to discuss confidential information.” B. “Let me check to see if they were admitted.” C. “The doctor said they will be alright.” D. “You should call the hospital and ask.” 32.

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Prior to discharging a fifteen-year-old who is asthmatic, the nursing should include which of the following measures in the teaching plan? A. Discussing techniques for weight control while taking steroids B. Identifying specific environmental triggers C. Maintaining school performance using a home tutor D. Keeping a record of weekly sputum testing

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4-hour transition period is over. mother is physically able. mother bathes after delivery. nurse gets an order from the baby’s doctor.

An obese woman complains of intense heartburn and asks the nurse to explain the reason for her problem. The nurse’s explanation should be based on which of the following statements? A. B. C. D.

An employee at a chemical plant is splashed in the eye with a chemical. The priority nursing intervention is to A. B. C. D.

A nurse is making a home health visit and finds the client experiencing right lower quadrant abdominal pain, which has decreased in intensity over the last day. The client also has a rigid abdomen and a temperature of 103.6ºF. The nurse should intervene by A. administering Tylenol (acetaminophen) for the elevated temperature. B. advising the client to increase oral fluids. C. asking the client when she last had a bowel movement. D. notifying the physician.

The client delivers a term infant with a 5minute Apgar score of 9. The client asks the nurse when she will be able to breastfeed her baby. The nurse should indicate that breastfeeding can begin as soon as the A. B. C. D.

A nurse is at the grocery store and his neighbor says, “I heard about that horrible car accident. They brought all the people to your hospital. How are they?” The nurse’s best response would be

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cover the eye with a gauge patch. place antibiotic ointment in the eye. rinse the eye continuously for 15 minutes. read the label on the chemical and call the emergency center.

Cardiac sphincter tone is decreased. Cardiac sphincter tone is increased. Gastric emptying time is increased. Dietary protein is inadequately digested.

A client is transferring to a chair for the first time following a posterior spinal fusion. To assist the client, the nurse should first A. secure a mechanical lift to transfer the client from bed to chair. B. have the client roll on his side, bend his knees, and sit up with assistance without bending his trunk. C. pull the client to a sitting position using his arms and turn him to dangle on the side of the bed. D. call physical therapy to supervise the transfer of the client.

What nursing action would be most effective in changing the behavior of a child diagnosed with attention deficit hyperactivity disorder (ADHA)? A. Reward appropriate behavior B. Sedate the child for acting out C. Use aggressive punishment to control undesired behavior D. Use lengthy time out session

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CD Rom: Practice Exam 1 35.

The most appropriate approach for the staff to take with the client who demonstrate manipulative aggressive behavior is to

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A. allow the client’s favorite nurse to be her primary counselor. B. sedate the client with medication at signs of aggression. C. set clear limits on the client’s behavior. D. tell the client that his behavior is disruptive to other clients. 36.

A. B. C. D. 40.

An insulin dependent diabetic client is preparing a mixed dose of insulin. The nurse is satisfied with the client’s performance when he

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A 65-year-old male is admitted to your unit. He says, “My wife and I have not been apart for 45 years”. Your best response would be

A 21-year-old female presents to the emergency department for treatment of bronchitis. During her discharge from the hospital, she says, “I don’t have any food for my baby”. The nurse’s best response would be

A client recently diagnosed with lung cancer says to the nurse, “I’m still going to smoke”. The nurse’s best response to this client would be A. B. C. D.

A. “It must be difficult for you to be separated from her.” B. “Your wife will be able to visit you every day.” C. “You’ll be fine once you get adjusted to the hospital routine.” D. “Your time in the hospital will pass very quickly.” 38.

Child abuse Employee abuse Martial abuse Spouse abuse

A. “How old is your baby?” B. “I’m sorry but there’s really nothing the hospital can do about that.” C. “Let’s discuss some alternatives for you.” D. “You should talk with your family about getting some assistance.”

A. Injects air into the bottle of short acting insulin first. B. injects air into the bottle of delayed acting insulin first. C. fills both syringes with the prescribed insulin dosage. D. withdraws the delayed action insulin before withdrawing the short acting insulin. 37.

Nurses have a legal responsibility to report suspected or actual cases of abuse in which of the following situations?

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The nursing supervisor observes a nursing assistant hit a client. The supervisor’s best response to the assistant would be A. B. C. D.

The nurse is providing care for a client with expressive and receptive aphasia. Which of the following measures represents the most appropriate means of communication when providing care to this client?

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A. Stand directly in front of the client while speaking. B. Clearly print all necessary information for the client to read. C. Communicate all essential information exclusively with the client’s wife. D. Use non-verbal communication when providing client care.

“I can’t believe you would still want to smoke.” “When did you start smoking?” “Let’s talk more about this.” “I’m sure your family will be upset.”

“You should not ever do that.” “We need to discuss this.” “I have to tell the boss.” “I can’t believe your did that.”

When maintaining accurate records in situations of suspected abuse, the nurse should document A. an interpretation of the client’s statements regarding the abuse. B. a body map to indicate size, color, areas and types of injuries. C. a description of the suspected abuser. D. generalized statements about the events leading up to the abuse.

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CD Rom: Practice Exam 1 44.

The spouse of a hearing impaired client requests that the nurse allow her husband to have his compact disc player on because he enjoys classical music. The nurse should comply with the spouse’s request because

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A. “Let me help you cut the food into small bites.” B. “Don’t you like the food?” C. “I’ll order you a soft diet.” D. “Let me look at your mouth and gums.”

A. the wife is denying the fact that her husband cannot hear. B. the vibrations of the music be felt by the husband. C. it is important to fulfill all family requests. D. it is the client’s wishes that are important. 45.

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A 35-year-old female admitted to the hospital is 5’6” and weighs 210 pounds. During the client’s discharge planning a priority nursing intervention would be to

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Which of the following statements best reflects client readiness for smoking cessation?

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Magnesium sulfate is administered intravenously to treat a client’s pregnancy induced hypertension. The nurse should monitor the client for which of the following adverse effects? A. B. C. D.

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when the catheter is for 10 seconds. while rotating the catheter

12-14 years 15-35 years 36-50 years Over 50 years of age

The nurse should anticipate that a client brought to the emergency room with methadone intoxication will be given which of the following medications? A. B. C. D.

Hyperreflexia Hyperventilation Decreased platelets Decreased respiratory rate

when the catheter is

At a community health class on cancer risk reduction, the nurse should instruct the group that men at risk for testicular cancer are those in which of the following age ranges? A. B. C. D.

A. “My doctor told me last year that I should quit.” B. I have been trying to quit for 2 years. C. “My mother died of lung cancer.” D. “I have been exercising and trying to cut back.” 47.

The supervisor observes a new graduate nurse suctioning a client. Which of the following techniques requires an intervention? A. Suction is applied withdrawn. B. Suction is applied inserted. C. Suction is applied D. Suction is applied 360 degrees.

A. help the client identify ways to decease daily caloric intake. B. Inform the client of the chronic diseases related to obesity. C. refer the client to a psychologist. D. discuss the client’s weight problem with the family. 46.

A 72-year-old female is getting ready to be discharged from the hospital. She tells the nurse that it is difficult for her to chew food. The nurse’s best response would be

Proventil (albuterol) Valium (diazepam) Narcan (naloxone) Demerol (meperidine)

CD Rom: Practice Exam 1 52.

Which of the following statements, if made by a client who has chronic paranoid schizophrenia, would indicate a correct understanding of the discharge instructions for antipsychotic medications?

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A. transfer the client to the cardiac intensive care unit. B. begin cardiopulmonary resuscitation. C. administer oxygen. D. lower the head of the bed.

A. “I will take this medication daily.” B. “I will take the medication when I start to feel anxious.” C. “I will need to take this medication for at least six months.” D. “I won’t need as much medication after I leave the hospital.” 53.

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An amniotomy is conducted on a client in labor. The nurse should monitor the client for which of the following adverse effects? A. B. C. D.

Fetal heart rate deceleration Fetal heart rate acceleration Leaking of copious amount of clear fluid Little or no amniotic fluid

A client who has a fractured hip is admitted to the hospital. The client’s hygiene is poor and her clothing is soiled. The nursing assistant says, “Isn’t this disgusting? I can’t believe anyone would take such poor care of herself.” The nurse’s most appropriate response would be A. B. C. D.

Which of the following recommendations should the nurse make to a pregnant adolescent who has an aversion to milk?

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A. “It’s important to drink milk during pregnancy even though you don’t like it.” B. “Milk products are not necessary as long as you take a daily 1200 mg calcium supplement.” C. “Adequate protein intake can be achieved by eating 2 eggs everyday.” D. “Adequate calcium intake can be achieved by eating a cup of spinach everyday.” 55.

A 2-day postoperative client suddenly becomes diaphoretic, dusky and short of breath. The nurse’s immediate response should be to

“Let’s get her cleaned up.” “You sound upset.” “I totally agree. This is awful.” “Not everyone is as fortunate as we are.”

A one-week-old breastfed infant is voiding 3 times a day. The mother asks the nurse if this is normal. The best response by the nurse is A. “If the baby looks healthy, there should be no problem.” B. “It is expected that the newborn will have at least 6 wet diapers a day.” C. “Maybe your milk supply is low.” D. “Wet diapers normally vary greatly among newborns. There is no set number of voids considered normal.”

The nurse is about to remove sutures on an Arabic male recovering from a colon resection. The client’s son, daughter and wife are with him. The nurse should realize that in the client’s culture

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A. family members participate in the client’s care. B. only a male family member may remain in the room during treatment procedures. C. a male nurse is the only acceptable care provider. D. all family members have to approve any procedures.

During an initial home visit post-hospitalization, the nurse note that the client has a history of recent stroke with residual left sided hemiparesis, slight aphasia, diminished gag reflex and emotional liability. The client outcome of highest priority is ability to A. communicate effectively. B. perform activities of daily living (ADLs) with assistance. C. ambulate with assistance. D. swallow liquids and solids without aspiration.

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CD Rom: Practice Exam 1 60.

Which of the following statements made by a client during a teaching session about osteoporosis management indicates the need for further instruction?

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A. Have the client eat in a brightly lit, stimulating dining room. B. Offer the client only room temperature foods C. Encourage the client to alternate thickened liquids and solids in small amounts. D. Encourage the client to hyperextend his neck when swallowing.

A. “I drink about 6 cups of tea a day, so I need to reduce my caffeine intake.” B. “I need to eat more seafood and dried beans.” C. “I will have to limit the amount of walking that I do.” D. I will talk to my doctor about the pros and cons of hormone replacement therapy. 61.

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The nurse is assigned to a client with a diagnosis of terminal cancer and an order for comfort measures only. Which of the following nursing interventions would have the highest priority for this client? A. B. C. D.

A client has been taking Zoloft (sertraline) for three months. Which of the following client statements indicates a need for further education?

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The clinic nurse should monitor which of the following tests to evaluate the over-all therapeutic compliance of a diabetic client with a normal serum hemoglobin? A. B. C. D.

The home health nurse assists a client with acquired immune deficiency syndrome (AIDS) to assess for pseudomembranous candidiasis by observing for A. B. C. D.

A client is admitted to the emergency department following an automobile accident. The client has four fractured ribs and a rightsided pneumothorax. Which of the following respiratory assessment findings would the nurse expect to find? A. Crackles on the right chest and a respiratory rate of 8 breaths/minute. B. Diminished breath sounds on the right and pain on inspiration. C. Bilateral rhonchi and pink frothy sputum. D. Dry cough and wheezing on the right side of the chest.

Performing a body systems assessment Measuring oxygen saturation level Assessing pain status Repositioning for comfort

A. I am taking my medication every week. B. I take my medication with breakfast. C. I am eating more cheese and fresh fruit in my diet. D. I enjoyed drinking several beers with my friends last night. 63.

To facilitate swallowing by a dysphagic client, the nurse should use which of the following techniques at mealtime?

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white plaques on oral surfaces. cracking and erythema of the nares. red, painful lesions in the outer ear canal. conjunctivitis of either or both eyes.

Fasting serum glucose Glycosylated hemoglobin Urine glucose and ketone levels Routine serum chemistry profile

A registered nurse and an unlicensed assistive personal (UAP) are assigned to a medical surgical unit. Which of the following tasks may be delegated by the nurse to the UAP? A. Administering a stool softener to the client B. Adjusting the rate of the intravenous solution of dextrose and water C. Assisting a blind client with his meal D. Obtaining initial vital signs on a client returning from the recovery room

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CD Rom: Practice Exam 1 68.

Which of the following physical assessment findings should indicate to the nurse that a client who received a renal transplant one month ago is experiencing acute organ rejection? A. B. C. D.

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A. B. C. D.

Distended abdomen Pink, sensitive incisional line Lower extremity edema Tenderness in lower abdomen 74.

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Which of the following breathing patterns would indicate to the nurse that a client with chronic asthma has improved respiratory status? A. B. C. D.

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A client with a thought disorder approaches the nurse and states, “I’m an Easter egg”. The nurse’s best response would be A. “No, you’re not an Easter egg.” B. “Tell me what you’re thinking when you say that.” C. “O.K., but you still need to attend groups.” D. “How long have you been feeling that way?”

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The nurse should instruct a client preparing for eye surgery that which of these activities will be restricted post-operatively? Bending with the knees flexed Bending from the waist Keeping the head in a neutral position Lying flat

The nurse is caring for a gravely ill young woman in the intensive care unit who has requested that the “pyramid” brought in by her family be placed under her bed. The best action by the nurse would be to A. comply with the client’s wishes. B. ask the family to take it home because it will be in the way. C. put it on the window ledge because of the equipment needed in the room. D. hang it from an intravenous pole to keep it away from medical equipment.

Which of the following statements would be most appropriate for the nurse to make when teaching a client with human papilloma virus (HPV)? A. B. C. D.

The most appropriate action for the nurse from geriatric care unit to take when asked to report for a shift in the surgical intensive care unit would be to

A. B. C. D.

increase. decrease. remain stable. fluctuate widely. 76.

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“I can continue swimming 3 times a week.” “I drink alcohol only on weekends.” “I will visit an eye doctor yearly.” “Relaxation for me is going to the movies.”

A. refuse the assignment immediately. B. notify the state board of nurse examiners. C. accept responsibility only for tasks for which the nurse is qualified. D. say nothing and comply with the request.

A rate of exhalation twice that of inhalation A rate of inhalation twice that of exhalation Slow, shallow inhalation Slow, shallow exhalation

When administering methylprednisolone (Solu-Medrol) to a client with IDDM (insulin dependent diabetes mellitus) the nurse would expect the client’s insulin requirement to A. B. C. D.

The nurse is teaching a hypertensive client about management of the disease. Which of these client statements indicates the greatest need for further instruction?

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“You may need to be treated again.” “You may resume your normal level of activity.” “You should have a pap smear.” “You need to continue your medication until symptoms subside.”

A new mother is worried that her baby will have trouble breathing while breastfeeding. The nurse should instruct the mother that the safest way to breastfeed is to A. depress the breast tissue around the baby’s nose. B. pull the nipple out of the baby’s mouth and let him breathe periodically. C. raise the baby’s hips slightly to change the angle of the head for breathing. D. make sure only the baby’s cheeks touch the breast, not the nose and chin.

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CD Rom: Practice Exam 1 78.

A client who was in a motor accident one month ago has been having flashbacks of the event. The nurse’s priority intervention during a flashback would be to A. B. C. D.

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A. “Wear sunglasses and use sunscreen when you are outdoors. B. “You must take the medication with a meal. C. “You may experience some minor muscle cramps. D. “Taking fat-soluble vitamins will promote absorption of the drug.

engage the client in alternate activities. initiate behavioral modification techniques. stay with the client. teach progressive relaxation exercises.

A new mother is breastfeeding her infant who is making loud clicking noises at the breast. The best intervention by the nurse would be to

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A. gently pull the baby off the breast and reposition. B. listen for audible swallowing. C. observe to make sure the entire areola is in the baby’s mouth. D. not intervene with the breastfeeding process. 80.

Four clients are admitted to the hospital following a car accident. Which of the following clients should the nurse assess first?

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Which of the following interventions should be added to the nursing care plan for a client who has difficulty swallowing after a stroke? A. B. C. D.

A client who just returned to his room after a transurethral prostatectomy (TURP) has continuous three-way bladder irrigation. The nurse notes that the drainage is dark red without clots. Which of the following actions should the nurse take? A. B. C. D.

The nurse caring for a client with an obsessive compulsive disorder should encourage the client to A. abruptly stop the ritualistic behavior. B. decrease the amount of time spent with family members who exacerbate the behavior. C. increase the amount of time spent practicing the ritualistic behavior. D. use thought- stopping behavior that allows that client to yell “ stop” when the behavior comes to mind.

A. A 27 year old complaining of a headache. B. An 18 year old with a compound fracture of the right arm. C. A 25 year old with blood on both pant legs. D. A 20 year old with epistaxis. 81.

Which of these discharge instructions should the nurse give to a client taking atorvastatin (Lipitor)?

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Increase the rate of irrigation. Notify the physician. Continue to monitor the drainage. Irrigate the catheter manually.

A nurse making a home visit to a client with a central line discovers a possible occlusion. Which of the following actions would the nurse implement initially before notifying the physician? A. B. C. D.

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Avoid salty foods Thicken liquids before feeding Elevate head of bed 360 degrees Place food in center of mouth

Infuse a thrombolytic agent Change the client’s position Have an X-ray taken Flush the line with sterile water

Which information is most important for the nurse to include in a teaching plan for a client with a laryngectomy? A. Contact a self-help group after discharge B. Protect the airway from dust C. Purchase special steroid cream for the stoma D. Maintain an upright position while eating and drinking

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CD Rom: Practice Exam 1 90.

A client’s infant is scheduled to have a circumcision. He is crying inconsolably and the mother appears distraught. The nurse should explain to the mother that the infant A. is probably hungry since he hasn’t eaten for a few hours. B. is probably frightened because babies sense danger. C. wants attention like most babies. D. probably needs to be swaddled more tightly.

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A. B. C. D.

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Which of these laboratory findings would indicate that simvastatin (Zocor) is having the desired effect? A. B. C. D.

The nurse suspects a client has been smoking crack cocaine when she observes which of the following assessment findings? A. B. C. D.

93.

A psychotic client is pacing, kicking the wall and talking loudly to himself. The best nursing response to this behavior would be to 98.

Which of the following would be a nursing priority for discharge planning of the aging client?

The best position for the client who is admitted with risk of increased intracranial pressure from a concussion would be A. B. C. D.

99. During the nursing history, a client states, “I have anemia”. The nursing care plan should include measures to A. B. C. D.

Constipation Bradycardia Insomnia Fatigue

A. Educating the client and family to remove throw rugs from the client’s apartment B. Speaking loudly to be certain that the client can hear you C. Encouraging the client to switch to a soft diet with fruit D. Recommending a low cholesterol diet to decrease risk of heart disease.

Euphoria and dilation of the pupil Red eyes and increased appetite Drowsiness and constricted pupils Depressed appetite and hallucinations

A. place the client in restraints immediately. B. approach the client and tell him that his behavior is inappropriate and needs to stop. C. offer the client a choice of talking about what’s upsetting him or spending some quiet time in his room. D. tell the client that if he doesn’t stop kicking the wall, you will put him in restraints. 94.

Monitor vital signs every hour Administer pain medication every 4 hours Encourage fluid intake to >2000ml/day Assess for numbness and tingling of extremities

The physician orders interferon alfa-2b for a client with hepatitis C. The nurse should assess the client for which of these side effects of the medication? A. B. C. D.

Lowered high density lipoproteins (HDL) Decreased triglycerides Elevated alanine aminotransferase (ALT) Increased aspartate aminotransferase (AST) 97.

92.

Which of the following nursing actions should be included in the care plan for a client with acute hypercalcemia?

promote hydration. prevent infection. alleviate fatigue. protect skin integrity.

Trendelenburg. Semi-fowler's. Sim’s lateral. Supine.

A client sustains a life-threatening head injury in a motor vehicle accident and is admitted to the hospital. The client’s wife approaches the nurse and asks, “Is he going to die?” The nurses best response would be A. We won’t let that happen. I know how much he means to you.” B. I will get the physician to talk to you as soon as possible.” C. He is very ill, and we’re doing the best we can for him. D. His condition is very serious and I will arrange for you to see him.

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CD Rom: Practice Exam 1 100. Which of the following post-procedure instructions should be included in the teaching plan for a client undergoing an arteriogram of the lower extremities?

105. A post partum mother who is a Jehovah’s Witness refuses a blood transfusion. After explaining the rationale for the transfusion, the nurse should

A. Nothing by mouth for at least 2 hours after the procedure B. Increased fluid intake for the first 4 hours after the procedure C. Conduct full range of motion exercises of the affected limb D. Remove pressure dressing after 1 hour

A. have the client sign a release from liability document. B. persuade the client to accept the blood transfusion. C. administer the blood transfusion as ordered. D. tell the client that the physician must decide the treatment options.

101. Which of these assessment findings in a client on long-term corticosteroid therapy would indicate a complication of this regimen? A. B. C. D.

Reduction in height Plantar flexion Hypertension Joint tophi or crystal deposits

A. “I have to cancel my hairdresser appointment.” B. “My daughter will be coming over to vacuum for a while.” C. I will not have to cancel my golf game. D. I will be able to cook something for tonight.

102. Which of these observations would be most important when caring for a client who has been using cocaine? A. B. C. D.

106. Which of the following statements by a client who has had a cataract removed would indicate a correct understanding of the nurse’s after-care instructions?

107. Which of the following medical orders for a client admitted with a diagnosis of pancreatitis would the nurse question?

Elevated blood pressure Anorexia Hallucinations Irritability

A. Complete blood count (CBC) now and in the AM B. Morphine 1 mg IM q 4 hours prn pain C. Prepare for insertion of central venous line D. Maintain NPO status

103. A client who has recently been prescribed chlorpromazine (Thorazine) complains of blurred vision and sensitivity to light. Nursing interventions should include A. instructing the client to wear sunglasses. B. stopping the medication and notifying the physician. C. scheduling an eye exam for the client. D. documenting the client’s somatic complaints.

108. A client who is postpartum and breastfeeding asks the nurse if lactation can be considered a contraception method. The nurse should indicate that contraception is an outcome in which of the following circumstances?

104. When the nurse teaches an elderly client about antihypertensive medications, it is important to include measures to prevent

A. Fulltime or nearly fulltime breastfeeding B. Regular menstrual periods C. Intercourse occurs less frequently than one time per week D. Infant uses a pacifier

A. B. C. D.

fluid retention. orthostatic hypotension. weight gain. constipation.

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CD Rom: Practice Exam 1 109. A newly delivered 28-week infant will be transported to a regional care center for critical care. Which of the following is considered essential before the infant is transported?

113. When teaching a community group about the risks of developing breast cancer, the nurse should identify which of the following conditions as putting individuals at greatest risk?

A. The nurse should explain all equipment to the mother. B. The mother should be allowed to see and touch her baby. C. The mother should breast feed the infant. D. The clergy visitation should be completed.

A. B. C. D.

Cigarette smoke Late menarche Familial history High caffeine intake

114. Which of the following findings would the nurse expect to see in a client diagnosed with metabolic acidosis?

110. The emergency department nurse has triaged 4 clients. Which client should be given priority treatment?

A. B. C. D

A. The 18-year-old with an impaled knife in the abdomen. B. The 40-year-old with sinus tachycardia and complaining of nausea, vomiting and diarrhea times 3 days. C. The 39-year-old with an obvious fracture of the right femur who is complaining of severe pain. D. The 22-year-old stung by a wasp and exhibiting stridor.

Hypercalcemia Hypernatremia Hyperkalemia Hypermagnesemia

115. A client in the emergency department who has been vomiting asks, “May I have some warm tea and toast to settle my stomach. I think it is better now” The laboratory results are normal. The nurse’s best response would be A. B. C. D.

111. A client brought to the emergency department appears very anxious and tearful. The nurse’s best response would be

“It is not good for you to eat or drink now.” “Let me check to see.” “You don’t seem well enough yet.” “That would not be a problem.”

116. A client admitted to the emergency department following a motor vehicle accident is alert and oriented and frequently requesting water. His blood pressure is 92/58, heart rate thready at 126 beats/minute, and his respirations shallow at 28/min. Skin pallor is noted. Which of the following interventions should the nurse perform first?

A. “I’m sure you have been in the hospital before.” B. “There is really nothing to worry about.” C. “I know this is frightening for you.” D. “The hospital really isn’t so bad.” 112. A client with bipolar disorder who is on lithium is ataxic and tremulous and vomited 2 hours ago. The nurse’s first priority would be to A. hold the next dose of lithium carbonate. B. take the client’s blood pressure in the supine position. C. request a neurological consult. D. assess for delirium tremens.

A. Insert an indwelling catheter to record hourly urinary output B. Provide sedation to relieve apprehension C. Administer oxygen at 6 liters by mask D. Administer whole unmatched blood 117. A client is eating food from other clients’ trays. The nurse’s best response is A. B. C. D.

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“Why are you eating food from those trays?” “You must leave the others alone.” “You really shouldn’t be doing that.” “Come with me and I will find you something to eat.”

CD Rom: Practice Exam 1 118. A client is attempting a trial of labor after a previous cesarean section. After 6 hours of normal labor, there is a sudden change in the contraction pattern, fetal bradycardia and a marked change in abdominal contour. The nurse should suspect which of the following conditions? A. B. C. D.

122. A client is receiving warfarin (Coumadin). Which of the following client statements indicates that the nurse’s medication instructions were effective? A. B. C. D.

Abruptio placenta Complete cervical dilation Uterine rupture Fetal demise

“I will double up for missed dosages.” “I will use a soft bristled toothbrush.” “I will eat more green leafy vegetables.” “I can take over the counter drugs for cold symptoms.”

123. Which of the following nursing measures would be most effective when communicating with a client who is mechanically ventilated by way of an oral endotracheal tube?

119. An elderly client previously awake, alert, and oriented tells you, “The president told me I should go and see about this leg’’. The most important nursing intervention at the time is to

A. Write questions you wish to ask the client on a note pad B. Ask open-ended questions so that client needs can be fully understood C. Use an alphabet board to allow the client to spell out needs D. Allow the client to mouth words to decrease frustration

A. do nothing as this is a normal alteration in the hospitalized elderly. B. obtain an order for a CAT (computerized axial tomography) scan of the brain. C. re-orient the client to reality. D. assess the client’s neurological status. 120. A pregnant client received butorphanol (Stadol) during labor and subsequently delivered an apneic infant. Positive pressure ventilation with 100% oxygen has been ineffective. Which of the following measures should the nurse anticipate the infant receiving next? A. Administering naloxone hydrochloride (Narcan) B. Giving dopamine (Intropin) by continuous infusion C. Positioning the infant onto the abdomen D. Providing packed red blood cells. 121. A newly admitted client with the suspected diagnosis of pulmonary tuberculosis (TB) is scheduled for a chest x-ray. Which of the following nursing actions should be taken? A. Clarify the order with the physician B. Request that a portable x-ray be done in the client’s room C. Instruct transport personnel to wear masks D. Instruct the client to wear a mask

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124. A client complains of left sided chest pain during a dressing change. Which of the following actions should the nurse implement immediately? A. Stop the procedure and administer oxygen B. Complete the dressing change and elevate the head of the bed C. Stop the procedure and administer pain medication D. Complete the dressing change and notify the physician 125. Which of the following laboratory values would indicate to the nurse a serious complication for the client who has had a radiology procedure using contrast dye? A. B. C. D.

Hemoglobin 12-18 gm/dl Sodium 137meg/dl Creatinine 1.0 mg/dl Blood urea nitrogen 30 mg/dl

CD Rom: Practice Exam 1 126. A client is court ordered to take psychiatric medications. Medication administration procedures for this client should include A. giving the client 8 oz of juice to take with the medication B. leaving the medication in the client’s room for self-administration C. crushing the medication prior to administration D. checking inside the client’s mouth after administration 127. A client with a chest tube connected to wall suction is being repositioned when electrical power is suddenly interrupted. Which of the following actions should the nurse carry out first? A. Clamp the chest tube close to the chest wall B. Reassure the client and wait for the power to return C. Milk the chest tube to prevent clot formation D. Reposition the client on the chest tube site and apply pressure 128. A newborn died from an intraventricular hemorrhage. Which of the following responses would be most appropriate for the nurse to make to the mother?

129. After signing the surgery permit a client states, “If I have to be completely put to sleep, I don’t want surgery”. Which of the following responses by the nurse is most appropriate? A. “You agreed to this when you talked to the doctor.” B. “Let me call your family and you can talk about this together.” C. “The anesthesiologist is on the area. I will request that he talk to you.” D. “I will page your doctor and he will talk with you some more.” 130. When caring for a client who has sustained a closed head injury, which of the following vital sign changes should the nurse report immediately? A. Temperature change from 36.5° to 37° C B. Heart rate change from 82/min to 88/min C. Respiratory rate change from 12/min to 16/min D. Blood pressure change from 110/70 to 130/60. 131. A client expresses to the nurse that he does not understand why the surgery the physician is proposing is necessary. The most appropriate nursing measure at this time would be to

A. “Well at least your baby is with God now and is not suffering from brain damage.” B. “Would you like for me to be with you while your hold your baby?” C. “I know that it does not seem possible right now, but you can get pregnant again.” D. “Just try to think about how wonderful your pregnancy was.”

A. explain the procedure to the client. B. describe to the client the benefits of the surgery. C. ask the physician to re-discuss the surgery with the client. D. ask the family to explain the surgery and its benefits to the client. 132. A pregnant client infected with the human immunodeficiency virus (HIV) asks the nurse if anything can reduce the risk of transmission to her baby. The nurse should recommend which of the following interventions? A. Douching every day during the last month of pregnancy B. Receiving the HIV vaccination C. Taking zidovudine (ZVD) during pregnancy D. Separating the mother and child for 1 month postpartum

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CD Rom: Practice Exam 1 133. A client experiencing an acute asthmatic attack has received 3 albuterol aerosol treatments. Which of the following outcomes should the nurse expect? A. B. C. D.

138. The nurse counsels a client who has been prescribed a loop diuretic to supplement her diet with foods high in A. B. C. D.

Increased forced expiratory volume (FEV) Decreased forced expiratory (FEV) Increased inspiratory capacity (IC) Decreased inspiratory capacity (IC)

139. An appropriate postpartal resource for breastfeeding mothers is the

134. During an appointment at the health clinic a client is diagnosed with gonorrhea. Appropriate nursing education should focus on which of the following areas? A. B. C. D.

A. B. C. D.

Partner notification Douching techniques Use of vaginal suppositories Need for immediate hospitalization

135. The nurse is monitoring a client with the diagnosis of meningitis. Which of the following observations should the nurse report immediately? A. B. C. D.

Nuchal rigidity Seizure activity Fever Headache

136. To which of the following assessment data should the nurse give highest priority for a client admitted to the emergency room in a hepatic coma? A. B. C. D.

sodium potassium calcium magnesium

birthing center. community prenatal class. Lamaze class. La Leche league.

140. A client presents to the emergency department with complaints of substernal chest pain. Which standing order should the triage nurse initiate first? A. Administer oxygen at 4 liters per minute B. Administer nitroglycerin 1/150 grains sublingually C. Start an intravenous line with D5W to keep the vein open D. Administer morphine 2 mg as an intravenous bolus 141. Following a laparoscopic cholecystectomy the nurse find the client crying and moaning. The most appropriate nursing intervention at this time would be to

Neurological status Airway adequacy Ammonia levels Gastrointestinal bleeding

137. The nurse is teaching a wellness promotion course to male college students. The nurse should indicate the importance of doing testicular self-examination at which time? A. Monthly after a warm bath or shower B. Whenever they experience pain in or itching of the scrotum C. Every other month until the age of 40, than monthly D. Weekly at the same time of day

A. go to the nurse’s station and obtain the client’s pain medication. B. evaluate the client’s abdomen and incision sites for indications of complications. C. assess the client’s pain using a pain scale. D. ask the client if she would like to have her pain medication. 142. The nurse should be aware that a client is susceptible to spontaneous bleeding if taking which of the following herbs with an anticoagulant? A. B. C. D.

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Black cohosh Gingko biloba Chamomile tea Valerian root

CD Rom: Practice Exam 1 143. Which of the following laboratory results would the nurse expect to observe in a client with metabolic alkalosis? A. B. C. D.

Ph Ph Ph Ph

7.48; 7.31; 7.16; 7.18;

pCO2 43; HCO3 33 CO2 44; HCO3 20 CO2 57; HCO3 25 CO2 41; HCO3 14

A. “I will start walking a little more each day.” B. “I will use my stationary bike at least three times day.” C. “I will walk up and down the steps instead of taking the elevator.” D. “I will enroll in a deep water exercise class.”

144. A client who has been deaf since early childhood is admitted for same day surgery. Which of the following actions would be the most appropriate for the nurse conducting the discharge planning?

148. A xylocaine (Lidocaine) IV drip of 2.0 mg per minute is ordered for the client with frequent premature ventricular contractions. The nurse has available an IV of 20mg of Lidocaine in 500 ml of D5W. How many ml/hr should the nurse administer?

A. Ask for an interpreter who can sign during the teaching sessions B. Give the client reference material to read on her own C. Ask the unit manager to conduct the teaching session D. Call a colleague who signs and ask her how to proceed

A. B. C. D.

145. As the charge nurse is making staff assignments, a nurse colleague says, “I knew it. I’ve had the same assignment for the last 2 days.” The charge nurse’s most appropriate response would be A. B. C. D.

147. The nurse instructs a client with osteoporosis about exercises that will improve her condition. Which of the following client statements indicates a need for further instructions?

“I can’t believe you are reacting this way.” “I can’t do anything about this now.” “I’m sorry you feel that way.” “Let’s see how we can adjust your assignment.”

149. The physician prescribes fluoxetine (Prozac). Before starting this medication, it is most important for the nurse to ask the client if he takes which of the following herbs? A. B. C. D.

146. A physician ordered naloxone (Narcan) 4 mg IV stat for an infant who weighs 4 kg. Which of the following measures is appropriate for the nurse to take at this time?

60 45 30 15

St. John’s wort Valerian root Black cohosh Chamomile tea

150. A client has been admitted to the hospital with acute pancreatitis. The nurse should anticipate that the physician will order which of the following analgesics?

A. Give the drug as ordered B. Hold the drug until the infant’s respirations have stabilized C. Question the physician about the order D. Recheck the infant’s weight

A. B. C. D.

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Meperidene hydrochloride (Demerol) Morphine sulfate (MS Contin) Hydrocodone (Vicodin) Hydromorphone (Dilaudid)

CD Rom: Practice Exam 1 151. A primipara asks the nurse how long it will take for her to really feel as if she is a mother. How should the nurse best respond? A. “Not until you have had your second baby.” B. “It does vary but it would be normal if it took almost a year.” C. “It will take a couple of years for it to all come together.” D. “It will happen when you have mastered feeding, bathing, and diapering.” 152. A client tells the nurse, “I don’t know why the doctor prescribed this medication. I can’t possibly pay for this”. The nurse’s most appropriate response would be? A. “I am so sorry. There really isn’t much I can do.” B. “Here, let me give you some free samples.” C. “Let me contact social services. Maybe they can help.” D. “Let’s call your family so you can borrow the money from them.”

A. “Mothers should rely on their instincts, which are usually correct.” B. “Babies should be fed when it is most convenient for mother and infant.” C. “The newborn requires feeding when he gets irritable and makes kicking movements.” D. “Early feeding clues are infant hand to mouth movements.”

has been written in the record. is periodically updated. was given verbally over the phone. included family participation in the decision.

154. Which nursing measure will have the greatest priority in planning care for a client with acute hepatitis C? A. B. C. D.

Decreasing fluid intake Providing a low carbohydrate diet Providing rest periods Promoting social interaction

155. A client has a peripherally inserted central venous catheter (PICC) for long-term antibiotic therapy. Prior to initial use the nurse must first A. B. C. D.

A. A 22 year old in labor who has contractions 6 minutes apart B. A 36 year old complaining of chest discomfort and ecchymosis over the sternum following a motor vehicle accident C. A 50 year old wearing tin foil wrap and commanding people to travel to “una” as the universe has dictated D. A 44 year old who is 3 days post cholecystectomy presenting with a temperature of 103°F and purulent drainage from the incision 157. A new mother asks the postpartum nurse how she will know when she should breastfeed her newborn. The best response by the nurse would be

153. The nurse caring for a terminally ill client should be aware that a do not resuscitate (DNR) order is unacceptable if the order A. B. C. D.

156. Which of the following clients presenting to the emergency department simultaneously should be triaged as needing immediate attention?

assess for blood return in all ports. ensure patency by flushing. verify PICC placement with chest x-ray. obtain a complete blood count (CBC).

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158. A client has been prescribed furosemide (Lasix) daily. A nursing priority for client education is A. informing the client that he may experience some dizziness while on the medication. B. telling the client to stop the medication immediately if he feels joint discomfort. C. instructing the client on the importance of taking the medication every day, even if he does not feel well. D. teaching the client to take the medication at bedtime.

CD Rom: Practice Exam 1 159. A client who develops neutropenia following chemotherapy should be assessed by the nurse for which of these complications? A. B. C. D.

Bleeding Infection Alopecia Anorexia

A. B. C. D.

160. The nurse should be aware that which of the following therapies is most effective in producing behavioral change in a school-aged client who has a conduct disorder? A. B. C. D.

Post-operative hemorrhage Pulmonary embolism Acute infection Drug reaction

165. A client who has been diagnosed with osteoporosis should be discouraged from ingesting which of the following substance?

Therapeutic play Dramatic play Antipsychotic drug therapy Rewards for appropriate behavior

A. B. C. D.

161. The nurse should give the client taking warfarin (Coumadin) which of these instructions?

Milk Coffee Collard greens Sardines

166. Which of the following statements, if made by a client who has active tuberculosis, indicates that client teaching has been effective?

A. “Avoid taking any Vitamin E supplements.” B. “Be sure to eat lots of green leafy vegetables.” C. “Don’t drink milk because it will inactivate your medication.” D. “You should take extra Vitamin C.”

A. “The other nurse told me that everyone living with me will have to take these pills for 6 months.” B. “My doctor will also order penicillin.” C. “I’m glad that I won’t be contagious after I start taking the pills.” D. “My next skin test is scheduled to be done in 3 months.”

162. A client who had a cesarean birth asks the nurse when she can begin eating solid food again. The nurse should provide solid food when the client A. B. C. D.

164. An elderly client 2 days post-operative for a total hip replacement is noted to be restless and irritable. Respirations are 22/min, pulse 104 beats/min and pulse oximetry 90%. The nurse should suspect which of the following complications?

167. When caring for a client with an arteriovenous (AV) fistula, the nurse should be aware that the priority assessment would be

is able to ambulate unassisted. requests more substantial meals. has bowel sounds present. is able to pass flatus.

A. pulses distal to the fistula site. B. neurovascular status of the extremity distal to the fistula. C. auscultation of a bruit over the fistula. D. a feeling of warmth over the fistula.

163. An 81-year-old fractured her ankle and is told by the physician that she will need to use a walker for safe ambulation. The client says to the nurse, “Well, why can’t I use crutches?” The nurse’s best response to the client is A. “I knew you wouldn’t like the walker, but it is necessary.” B. “You could probably use crutches. Let me ask.” C. “Crutches would not be good for you at your age.” D. “The walker will provide better support for you.”

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CD Rom: Practice Exam 1 168. The nurse is assessing a male client who had a Foley catheter inserted 1 day ago. The client says, “This is so painful. I don’t think I can tolerate it any longer”. The nurse’s priority intervention would be to

172. The nurse is triaging clients in the emergency department. Which of the following clients should be evaluated first? A. B. C. D.

A. inspect the penis and catheter drainage system. B. notify the physician of the client’s complaint. C. remind the client that it has only been 1 day since insertion of the catheter. D. reassure the client that it is normal to feel this way.

173. Which of the following client assignments would be appropriate for a charge nurse to give to a licensed practical nurse (LPN)?

169. A client admitted to a psychiatric unit was taking methadone prior to admission. Which of the following actions should the nurse take first? A. Tell the client that methadone cannot be administered on the psychiatric unit. B. Call the physician for a methadone order. C. Contact the out-patient methadone clinic to verify the client’s treatment regime. D. Tell the client that other medications will be used on the unit.

A. A 52 year old client admitted last evening with a diagnosis of hepatic encephalopathy B. A 45 year old client who is 2 days post open reduction, internal fixation of the left femur C. An 18 year old client admitted 4 hours ago with infective endocarditis D. A 39 year old client who is 1 day post status asthmaticus 174. A breastfed infant develops colic each time the mother eats ice cream. The nurse should instruct the mother that the most likely cause of the colic is that the A. breast milk consistency is too thick. B. infant is receiving too much calcium in the breast milk. C. infant does not like the taste of the breast milk. D. infant is reacting to the milk protein.

170. The nurse assigned to a terminally ill client will require additional instructions if the nurse A. uses the clients own language with reference to death. B. facilitates transition of care from cure focus to palliation. C. tells the client everything will be all right. D. uses guided imagery for client pain relief. 171. The nurse is caring for a client following cranial surgery. The nurse should be aware that which of the following signs is an early indication of increasing intracranial pressure? A. B. C. D.

A 65 year old with abdominal pain A 15 year old with a lacerated leg A 2 year old with a 2-day history of diarrhea A 30 year old with shortness of breath

Hypertension Tachycardia Muscular rigidity Vomiting

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175. The nurse is preparing a client for discharge and self-care. The client will be taking furosimide (Lasix) 40 mg po BID. The client should be instructed to monitor for symptoms of hypokalemia, which include A. B. C. D.

fatigue and leg cramps. bruising and sore throat. constipation and photosensitivity. skin rash and visual disturbances.

CD Rom: Practice Exam 1 176. When entering a room to assess a new client, the nurse identifies that the client has brought with him a copy of the Torah. To further assess his spirituality, an appropriate statement would be A. “Would you like me to call a rabbi to see you?” B. “Would you like me to read the Torah to you during your stay?” C. “Are there any particular religious practices that are important to you?” D. “Would you like me to call the hospital chaplain to see you?” 177. A pregnant client tells the nurse that she is afraid her baby will have a spinal cord defect because her friend’s baby did. Which of the following response by the nurse would be most appropriate? A. “I’m sure that the doctor would have told you if anything were wrong with your baby.” B. “There is a test to see if you are at high risk.” C. “You are not at risk until late in your pregnancy.” D. “Perhaps you should consider amniocenteses.” 178. The culturally sensitive nurse should question which of the following menu selections served to her Islamic client? A. B. C. D.

Poached salmon, rice, green salad and tea Beef stew, potatoes, carrots and milk Ham steak, potato salad and apple pie Broiled lamb chops, buttered noodles and coffee

180. The nurse answers a call light for a client with preterm premature rupture of membranes. The client cries, “The baby is coming.” The nurse’s first action should be to A. B. C. D.

perform a sterile speculum exam. call for the primary care provider. inspect the introitus. call the neonatal team.

181. A client is admitted to the emergent department following ingestion of five tablets of Valium. Arterial blood gas analysis reveals a ph of 7.13; PO2 of 80; a pCO2 of 50; and an HCO3 of 25. The nurse would interpret the results as A. B. C. D.

respiratory acidosis. metabolic acidosis. respiratory alkalosis. metabolic alkalosis.

182. The nurse is assigned to the following four clients. Which client should the nurse assess first? A. A 50 year old receiving chemotherapy with a temperature of 101°F B. A 46 year old 2 days postoperative an open cholecystectomy C. A 52 year old newly diagnosed diabetic complaining of blurred vision D. A 40 year old ready for discharge to a rehabilitation center 183. The nurse is teaching a college student who was treated for seasonal affective disorder (SAD). The nurses should inform the student that the symptoms might return at which of the following times?

179. The nurse should be aware that an autopsy must be conducted in which of the following cases? A. A client who has died within 48 hours of admission to the hospital B. A client who has died within 96 hours of discharge from the hospital C. A child who has died D. A client who has died in his home

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A. When school ends in June B. During exposure to higher levels of sunlight in August C. When sunlight decreases in March D. When the holiday season ends in December

CD Rom: Practice Exam 1 184. A client is being discharged to home with a peripherally inserted central venous catheter (PICC). Which of the following outcome criteria is most important for this client? A. The client will verbalize the purpose of the PICC line B. The client will wear a Medic-alert bracelet indicating use of the catheter C. The client will flush the catheter daily with heparin D. The PICC insertion site will remain free of infection

A. B. C. D.

Tofu (soy bean curd) Broiled chicken Roast beef Fruit juice

189. A client in a health clinic reports smoking marijuana 2 hours ago and continues to have a heart rate of 200 beats per minute. Which of the following interventions is most important for the nurse to take?

185. A 15-year-old female is being evaluated in the emergency room for a fracture of her left arm. She says, “I tripped and fell.” You observe what appears to be cigarette burns on her arm. The most important nursing intervention is to

A. Conduct neurovascular checks every 30 minutes B. Increase IV fluids to 100 cc/hour C. Keep client awake D. Administer oxygen at 2L/min

A. tell nursing colleagues that you are certain this child is abused. B. ask the social worker to come and talk with the girl. C. notify the proper authorities right away. D. perform a complete physical assessment.

190. When caring for a client with a tunneled central venous catheter, which of the following manifestations requires immediate intervention by the nurse? A. B. C. D.

186. A client with angina who is taking nitroglycerin sustained-release (Nitrong) asks why he can’t take Viagra for his erectile dysfunction. Which of the following information should be included in the nurse’s response?

Redness at the catheter site Tenderness along the track of the catheter A loose dressing A small amount of blood in the dressing

191. A client falls while ambulating in the hospital hallway. After assessing the client and notifying the physician, the nurse should first

A. The Viagra will interfere with the effectiveness of the nitrogylcerine. B. The nitroglycerine may prevent the Viagra from working. C. Taken together the medications may cause fatal hypotension. D. When taken at the same time, neither one is effective.

A. accompany the client for follow-up x-ray. B. complete an incident report. C. re-assign the client to a room closer to the nurse’s station. D. document the event in the client’s care plan.

187. A client with multiple IV sites is to begin receiving total parental nutrition (TPN). The most appropriate IV access site would be the peripherally inserted central venous (PICC) catheter in the A. B. C. D.

188. A client adds all of the following foods to her diet after nursing instruction on the role of nutrition in the prevention of osteoporosis. Which food choice indicates a correct understanding of the teaching?

femoral vein. cephalic vein. basilic vein. subclavian vein.

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CD Rom: Practice Exam 1 192. The nurse can best help a client and family members to communicate with each other by A. reminding the family to maintain a positive attitude in the presence of the client. B. having the chaplain talk with the family. C. providing non-judgmental feedback as they express their emotions. D. limiting visiting hours to ensure adequate rest for the client.

A. B. C. D.

Nasal oxygen set-up Oral suction Intravenous infusion Oral airway

197. Which of these medication orders for a client who has asthma should the nurse question?

193. A client is prescribed alendronate (Fosomax). The nurse should include which of the following information in the client’s teaching plan?

A. B. C. D.

A. Take the medication 2 hours after you eat dinner. B. The medication must be taken 1 hour after lunch. C. Take over-the-counter Zantac for stomach upsets. D. Remain upright for 30 minutes after taking the medication.

Acetaminophen (Tylenol) Timolol (Timoptic) Cromolyn (Nasalcrom) Prednisone

198. A large number of family members are gathered at the bedside of a terminally ill Hispanic client in a semi-private room. Recognizing the family’s cultural response to death and dying, the nurse should

194. What would the nurse’s best response be to a client following the 12-step program for an addiction to huffing gasoline? A. “Developing will power is the best thing for you to do.” B. “You’ll be glad to get your life back in order.” C. “Just try to stay away from huffing one day at a time.” D. “Huffing can really destroy your life.” 195. A client arrives in the emergency department complaining of severe headache. On examination the nurse notes a skull depression surrounded by dried blood over the temporal area. The nurse should recognize this finding as A. B. C. D.

196. When preparing to admit a surgical client who has just had a tracheostomy, the nurse would need to have which of the following equipment available?

A. restrict visitors to two at a time in the client’s room. B. move the client to a private room to allow family to be with the client. C. have security limit the members of the family who can visit at one time D. ask the family members to show greater emotional control around the client. 199. The client in labor describes intense pain in her back during contractions. The best supportive measure by the nurse is to A. B. C. D.

blunt force trauma. penetration trauma. primary trauma. acceleration trauma.

instruct the client in breathing techniques. apply counter pressure to the client’s back. place a cool cloth on the mothers’ forehead. offer the client the option of epidural anesthesia.

200. A client taking indomethacin (Indocin SR) for rheumatoid arthritis is cautioned to report which of the following side effects of the medication? A. B. C. D.

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Depression Gastrointestinal disturbances Joint swelling Floaters in the field of vision

CD Rom: Practice Exam 1 201. The best indicator of the effectiveness of pain control while a client is receiving pain medication by patient-controlled analgesia (PCA) is the client A. B. C. D.

205. A client at 28 weeks gestation is admitted to the hospital for sudden onset of copious vaginal bleeding. To which of the following measures should the nurse give priority?

sleeping for long intervals. being free from grimacing. awakening to voice command. stating pain has reduced in severity.

A. B. C. D.

202. Tissue plasminogen activator (t-PA) is ordered for clients diagnosed with acute myocardial Infarction. Which of the following clients would be an acceptable candidate for t-PA?

206. A client the nurse has been working with for over a week approaches her and states, “You’re a terrible nurse and you don’t know what you are doing.” The nurse’s best response would be

A. A 42 year old being followed by a physician for hypertension control B. A 56 year old with a past medical history of status asthmaticus C. An 80-year-old who is 3 weeks post hip replacement D. A 38 year old with a medical history of thrombocytopenia 203. A client is admitted to the emergency department with an acute myocardial Infarction. Tissue plasminogen activator (t-PA) is ordered. Which of the following signs indicates a complication of this therapy? A. B. C. D.

Assessment of fatal heart tones Evaluation of maternal blood loss Determination of fetal presentation Assessment of cervical dilatation

A. B. C. D.

207. A client with pleural effusion has a chest tube inserted and connected to a closed chest drainage system. Which of the following findings would require immediate nursing intervention? A. B. C. D.

Shortness of breath Increased blood pressure Vomiting Epistaxis

“You seem angry” “Why do you think I’m a terrible nurse?” “Have I done something wrong?” “I do not like to be spoken to that way!”

Continuous bubbling in the drainage chamber Straw colored drainage in the tubing Tenderness at the insertion site Movement of fluid in the tubing during the respiratory cycle

208. A nurse observes a colleague taking all of the following actions when caring for a client with a peripherally inserted ventral venous catheter (PICC). Which action would the nurse intervene to stop?

204. A client keeps her insulin in the refrigerator in the summer because her house is not airconditioned. When the nurse removes the NPH insulin from the refrigerator, the vial was frozen. Which of the following actions should the nurse take?

A. Changing the dressing over the PICC line B. Drawing a sample of blood from the PICC line C. Taking a blood pressure on the same arm as the PICC line D. Flushing the PICC line with saline followed by heparinized saline

A. Place the insulin vial in a container of warm water B. Put the insulin in the microwave on the defrost setting C. Discard the vial and replace it with another for the needed dose D. Gently rotate the vial in the palms of the hands to mix it as it thaws

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CD Rom: Practice Exam 1 209. A nurse is instructing a client who had a gastric resection about measures to prevent dumping syndrome. Which of the following instructions related to fluid intake would the nurse give to the client? A. Drink fluids with meals B. Take fluids one hour before and one hour after meals C. Drink fluids between meals D. Drink fluids upon arising and again before going to bed

A. B. C. D.

A. decrease the infusion rate until the pain is relieved. B. apply dry heat to the area for 10 minutes. C. discontinue the infusion and notify the physician. D. stop the infusion and ice pack the affected site for 5 minutes.

A. B. C. D.

20 42 50 66

216. The nurse enters the room of a client who is in labor and lying supine without a pillow in the bed. The initial nursing response that best supports maternal-fetal well being is to

211. Entering the client’s room, the nurse observes the client to be cyanotic, cool to touch and diaphoretic. Which of the following actions should the nurse carry out first?

A. B. C. D.

Use verbal and tactile stimuli Apply oxygen at 10L/min via mask Assess heart and lung sounds Call for help

212. A client tells the nurse, “No matter what I do, I fail.” A nurse familiar with cognitive therapy would recommend that the client A. take a long walk to escape her thoughts. B. begin journaling about her dysfunctional, self-deprecating thoughts. C. request an increase in her antidepressant medication. D. discuss flooding techniques with her therapist. 213. A nurse observes a colleague taking all the following actions. Which action should the nurse intervene to stop? A. B. C. D.

intracranial pressure. hemodynamic status. respiratory function. fluid balance.

215. The following order is written for a client with deep vein thrombosis: Heparin 20,000 units in 1000ml D5W to infuse at 1000 units of heparin per hour. How many ml of D5W solution should be administered per hour?

210. A client receiving a dopamine infusion complains of severe pain and burning at the infusion site. The nurse’s immediate action should be to

A. B. C. D.

214. The nurse is conducting a teaching session with a client who has a pulmonary catheter (Swan-Ganz). The nurse would explain to the client that the information obtained from the pulmonary catheter measurements is indicative of the client’s

Cutting a scored pill in half Crushing Calan SR (verapamil SR) Crushing digoxin Removing the wrapper of a unit dose medication at the client’s bedside

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give the client a pillow. observe the client’s fetal monitor. assist the client to turn on her side. raise the head of the client’s bed.

217. While administering IV diazepam (Valium) through a primary IV port, the nurse notices the formation of a white precipitant in the IV tubing. The nurse’s immediate action should be to A. stop the primary IV and bolus the remaining Valium. B. increase the primary IV rate and stop the Valium until the tubing is clean. C. stop the administration of both infusions. D. stop the primary infusion and clear the tubing with sterile normal saline.

CD Rom: Practice Exam 1 218. When caring for a client with upper airway trauma resulting from smoke and heat inhalation, the nurse should assess for A. B. C. D.

hoarseness and stridor. post nasal drainage. stomatitis of the oral mucosa. hyperemia of the face and arms.

A. Reposition the client, provide a back rub and dim the lights B. Administer the non-narcotic pain reliever as ordered C. Administer the benzodiazepine to decrease symptoms D. Administer narcotic pain reliever as ordered

219. A nurse is assigned to care for all the following clients. Which client should the nurse assess first? A. A post-operative client who returned from the PACUL (Post Anesthesia Care Unit) one hour ago following a sub-total thyroidectomy. The client has stable vital signs and controlled pain. B. A client admitted from the emergency department one hour ago with acute abdominal pain and hypertension. The client is to go to the operating room in an hour for an exploratory laparotomy. C. A client with unstable atrial fibrillation admitted 24 hours ago. The client is on telemetry and has a low but stable blood pressure. D. A client with pneumonia admitted 48 hours ago who has a pending discharge to home order. 220. A client tells the mental health nurse that she can no longer tolerate her medication’s side effects and has quit taking the medicine. The nurse’s best response would be A. “That’s your right. You don’t have to take the medicine.” B. “Tell me more about the medicine’s side effects and how you’re feeling now.” C. “You have to take your medicine. It’s the law.” D. “It must not have been the best medicine for you, so it is a good decision.” 221. For dietary planning, the nurse would expect the client of Asian- American heritage to choose primarily from which of the following food groups? A. B. C. D.

222. A client with long-term substance abuse requests pain medication immediately following surgery. Which of the following actions by the nurse would be most appropriate?

Milk and dairy products Breads, starches and cereals Meats and poultry Vegetables and fruits

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223. A nurse is instructing a client about the correct use of a metered dose inhaler. Which of the following instructions should the nurse stress? A. “Hold your breath for 10 seconds after administering a dose.” B. “Administer 2 puffs with each inhalation.” C. “Do not shaking the inhaler before use.” D. “Activate the inhaler while breathing in slowly through your nose.” 224. Following an esophagogastroduodenoscopy (EGD), the nurse should assess the client for which of the following manifestations? A. B. C. D.

Zollinger-Ellison syndrome Epigastric pain Bell’s palsy Hypertension

225. Which of the following changes in fetal heart rate should the nurse recognize as indicative of potential abruptio placenta in the first few hours after a client has sustained trauma in a motor vehicle accident? A. B. C. D.

Early decelerations Variable decelerations Late decelerations Accelerations

CD Rom: Practice Exam 1 226. The teaching plan for a client who is taking alendronate sodium (Fosomax) should include which of the following instructions?

230. A client says to the nurse, “My doctor told me they are going to do some kind of test on me. I really didn’t understand it.” The nurse’s best response would be

A. Take the medication with food B. Sit up for at least 30 minutes after drinking fluids C. Avoid dark green, leafy vegetables D. Increase vitamin C in the diet 227. A visitor approaches the nurse in the hallway and demands to know what is going on with his mother. The nurse is not assigned to care for the visitor’s mother. The nurse’s best response would be A. B. C. D.

“Let me help you find out about your mother.” “Your mother is not my client.” “I don’t know anything about your mother.” “There’s no need to be so upset. I am sure someone will help you.”

228. The nurse should instruct a Chinese client who is pregnant about alternatives for which of the following food groups? A. B. C. D.

Cereals and breads Fruits and vegetables Meats and fish Milk and cheese

A. “Tell me your concerns.” B. “In the future tell your doctor he needs to speak more loudly.” C. “I would not worry about it too much. There is no pain involved.” D. “I’m sure you will be fine once you see what they are doing.” 231. It is necessary for a nurse in the long term care facility to take telephone orders from a physician. Which of the following nursing actions would be considered incorrect in this situation? A. Repeating the full order back to the physician B. Calling the pharmacy to question a dosage the physician has ordered C. Asking the physician to repeat an order that is not clear D. Using full words when writing the order instead of abbreviations 232. The nurse is giving discharge instructions to an Asian-American client who smiles and nods her head as she listens. The nurse should interpret this behavior to mean that the client

229. An Orthodox Jewish man in the intensive care unit is dying. Which of these statements by the nurse would indicate sensitivity to his cultural/ religious beliefs?

A. agrees to follow the instructions. B. is happy to be going home to her extended family. C. is demonstrating culturally-appropriate behavior. D. understands the instructions.

A. “I’m sorry but visiting hours are over now and your visitors will have to leave.” B. “Shall I call the rabbi to perform last rites for you?” C. “Would you like an autopsy performed after your death?” D. “Do you want us to call the rest of your family to be here with you?”

233. A Chinese immigrant failed to come to her first scheduled newborn check-up. From a cultural perspective, which of the following rationales for this behavior is most plausible? A. Travel in cars is not permitted for 3 months after birth B. The baby’s face cannot be exposed for 14 days after birth C. The mother and baby cannot leave the house for 40 days after birth D. There is a fear of evil spirits if the baby is touched by persons other than family for 2 months after birth

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CD Rom: Practice Exam 1 234. A client is admitted to the emergency department with a knife handle protruding from her chest wall. The nurse’s immediate action should be to A. B. C. D.

238. A client dies in the emergency department following a physical assault. To maintain legal integrity, the nurse’s most important responsibility is to

remove the knife and dress the wound. administer pain medication and oxygen. assess breath and heart sounds. obtain the history and notify law enforcement.

A. notify the medical examiner of the client’s death. B. document activities of law enforcement and staff. C. remove invasive lines from the client. D. pack up all client belongings.

235. The physician has written an order for 8 mg of morphine sulfate, q 4 hours PRN, subcutaneous (SQ) to relieve pain. The nurse should A. B. C. D.

239. Which assessment finding, if identified in a 70 year old client who has a fractured left femur, would require immediate follow-up by the nurse?

give the medication as ordered. ask the physician to order the IV route. do not give the medication as ordered. use complementary methods for pain control

A. B. C. D.

236. A nurse observes a colleague taking all of the following actions when charting. Which action should the nurse discuss with the colleague? A. Crossing out a documentation error with one line and placing the word ‘error’ and his initials above the line B. Crossing out documentation with one line and placing the word error and his name above the line C. Erasing an entry and placing his initials above the area D. Writing on every line and leaving no blank spaces 237. The nurse sees a new mother placing an amulet on her baby’s gown. The nurse’s action should be to

Urinary output of 50 cc/hr Change in mental status Pain in the left femur Redness at the incision site

240. The nurse is planning discharge teaching for a client who was treated for a new onset of angina. The physician has written the following prescriptions for the client. Which medication should the nurse question? A. B. C. D.

Viagra (sildenafil) Cardizem (diltiazem) Lopressor (metaprolol) Transderm (nitroglycerin)

241. Which of the following statements by the nurse would be most appropriate when the nurse is asked to obtain consent from an 18year-old undergoing major surgery? A. “I will have to speak with the parents for consent to operate.” B. “I will have to ask the client to read and sign the informed consent.” C. “The client’s physician should obtain the consent for surgery.” D. “There is no need for consent since the client is 18 years of age.”

A. remove the amulet and return it to the mother. B. ask the mother to remove the amulet until discharge. C. allow the amulet to remain on the gown. D. move the amulet to the side of the crib.

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CD Rom: Practice Exam 1 242. A client is admitted with a closed head injury and clear fluid draining from the left ear canal. Which of the following nursing interventions would be most appropriate for this client? A. Apply a sterile dressing over the ear and secure with tape B. Observe and document the color of the ear drainage C. Reposition the client to the right side to prevent further drainage D. Gently insert a sterile dressing into the ear and secure with sterile tape

A. B. C. D.

Frothy green discharge Scanty white discharge Thick creamy discharge Thin grayish-white discharge

247. A nurse is instructing the client about the side effects of the drug rofecoxib (Vioxx). Which of the following instructions would the nurse stress? A. B. C. D.

243. A client in active labor who has epidural anesthesia complains of discomfort in her lower abdomen. Then nurse’s first response should be to A. B. C. D.

246. The nurse is conducting a physical assessment on a patient diagnosed with trichomoniasis. Which of these observations of vaginal discharge would be the most significant?

call the anesthetist to reposition the epidural. call the midwife to prepare for delivery. turn the woman on to her side. palpate the area over the symphysis pubis.

“Call your physician if your ankles swell.” “Take this medication on an empty stomach.” “Take aspirin if you develop a headache.” “Store the tablets away from sunlight.”

248. A client is dead on arrival (DOA) to the emergency room following a single car accident. The nurse’s first action should be to A. B. C. D.

244. A client is instructed in how to use a patient controlled analgesia (PCA) pump following surgery. Which of the following statements by the client would indicate a correct understanding of use?

identify family members. close off the room to visitors. inform the Medical Examiner. transport the body to the morgue.

249. A pregnant client reports vaginal leaking of clear fluid. Which of the following assessments should the nurse carry out first?

A. “I will push the medication button when my pain begins to increase again.” B. “I will ask my wife to push the medication button while I am sleeping so that I don’t have pain.” C. “I will push the medication button when my pain becomes too severe.” D. “I will call the nurse when the pain begins to make me uncomfortable.”

A. B. C. D.

Test the fluid with Nitrazine paper Sterile vaginal exam Sterile speculum exam Test for ferning

250. A client with Alzheimer’s disease becomes extremely agitated. Which of the following initial nursing measures should be implemented to calm the client?

245. Which of the following explanations should the nurse give to a client regarding living wills? A. “They are mandated as a requirement of admission to a hospital.” B. “They allow you to direct your care in the event of a terminal illness or irreversible condition.” C. “They are legally binding on all caregivers” D. “They allow an individual identified by you to make decisions for your care.”

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A. B. C. D.

Brighten the lights Raise the side rails Ambulate the client Play soft music

CD Rom: Practice Exam 1

CD-Rom: Answers Practice Examination 1 Correct Answers for CGFNS CD-Rom Practice Examination 1 The following letters are the correct answers for each of the questions in the Practice Examination. 1 C 2 A 3 B 4 D 5 D 6. D 7 C 8 D 9 A 10 A 11 C 12 C 13 B 14 D 15 C 16 C 17 A 18 B 19 C 20 D 21 A 22 A 23 C 24 B 25 C 26 B 27 B 28 B 29 C 30 A 31 A 32 D 33 A 34 B 35 C 36 B 37 A 38 D 39 A

40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78

C C B B B A D D D B B C A A B A C B B B B D C C D A B C B B C D A A B A B C B

79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117

A C C B A A A D A B B A B A B C C D A B D B A A A B A D B A B D C A C C B C D

118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156

C D A D B C A D D B B D D C C A A B B A B D A C B A A D C D C A A B C C C C B

157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 30

D A B D A D D B B A C A C C C D B D A C B C A C A A C D D C D A D B B C D C A

196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234

B B B B B D B D C B A A C C C A B B B C C C A B B D D A B C B A D D A B C C C

235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250

B C C B B A B B D A B A A A C D

151

171

191

211

231

152

172

192

212

232

153

173

193

213

233

154

174

194

214

234

155

175

195

215

235

156

176

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216

236

157

177

197

217

237

158

178

198

218

238

159

179

199

219

239

160

180

200

220

240

161

181

201

221

241

162

182

202

222

242

163

183

203

223

243

164

184

204

224

244

165

185

205

225

245

166

186

206

226

246

167

187

207

227

247

168

188

208

228

248

169

189

209

229

249

170

190

210

230

250