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3.

A client as an obsessive-compulsive disorder
manifested by the compulsion of handwashing. The
nurse knows that which of the following best
describes the client’s need for the repetitive acts of
handwashing?
a. Handwashing represents an attempt to
manipulate the environment to make it
more comfortable.
b. Handwashing externalizes the anxiety from
a source within the bidy to an acceptable
substitute outside the body.
c. Handwashing assists the client to avoid
undesirable thoughts and maintain some
control over guilt and anxiety.
d. Handwashing helps to maintain the client in
an active state to resist the effects of
depression.
Following the vaginal delivery of an 11-pound baby,
the nurse encourages the mother to breastfeed her
newborn. What is the primary purpose of this action?
a. To initiate the secretion of colostrum
b. To prevent neonatal hyperglycemia
c. To facilitate maternal-newborn interaction.
d. To stimulate the uterus to contract.
Client is admitted for a series of tests to verify the
diagnosis of Cushing’s syndrome. Which of the
following assessment findings, if observed by the
nurse, would support this diagnosis?
a. Buffalo hump, hyperglycemia, and
hypernatremia
b. Nervousness, tachycardia, and intolerance
to heat
c. Lethargy, weight gain and intolerance to
cold
d. Irritability, moon face and dry skin

4.

The nurse is caring for a child with acute renal
failure who is in the intensive care unit. Which
assessment finding would indicate a sign of
tonsialemia?
a. Seizure
b. ECG changes
c. Dyspnea
d. Oliguria

5.

In planning care for a 7-year-old client with Grave’s
disease, what should the nurse do?
a. Encourage frequent rest periods
b. Encourage strenuous physical activity
c. Administer thyroid hormone replacement
daily
d. Encourage a decrease caloric intake

6.

The nurse recognizes which of the following as early
sign of lithium toxicity?
a. Restlessness, shuffling gait, involuntary
muscle movements
b. Ataxia, confusion, seizures
c. Fine tremors, nausea, vomiting, diarrhea
d. Elevated white blood cell count, orthostatic
hypotension

7.

The nurse is preparing to do a shift assessment on a
client who was admitted with an upper
gastrointestinal bleed. Which signs and symptoms
would indicate active bleeding? (Select all that
apply)
a. Blood pressure 80/52 mmHg
b. Stool black and tarry
c. Hemoglobin 18g/dL
d. Hematocrit 32%
e. Heart rate 128 beats/min
f. Respirations 32 and shallow
Mr. Rollins is a known alcoholic who is brought to the
Emergency Department by the police. He has severe
ascites from his chronic alcoholism and the physician
prescribes spironolactone 50mg orally now. The
pharmacy dispenses spironolactone 25mg tablets.
How many tablets do you give Mr. Rollins?
a. 2 tablets

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b.
c.
d.
9.

0.5 tablet
4 tablets
1 tablet

A client is admitted with suspected pneumonia. The
chest xray reveals right middle and lower lunch
consolidation. During auscultation of the middle and
lower lobes, which finding related to the pulmonary
system would the nurse anticipate?
a. Inspiratory and expiratory wheezing
b. Decreased breath sounds
c. Tympanic hyperresonance
d. Bronchovesicular sounds

10. Prior to electroconvulsive therapy (ECT) treatment,
the patient receives an injection of a medication
that reduces secretions and protects against vagal
bradycardia. Which medication will you administer?
a. Fluoxetine (Prozac)
b. Diphenhydramine (Bendaryl)
c. Atropine
d. Epinephrine (Adrenalin)
11. Patient with Alzheimer’s wandering in the hallway,
which of the following should the nurse do?
a. Place in soft restraints
b. Place in a restraint chair in the nurse
station
c. Place chemical restraints
d. Ask relative to stay with the patient
12. Mrs. Robinson is a 38 year old woman being treated
on an outpatient basis for depression. Three months
ago, her husband revealed that he was having an
affair with her best friend and planned to file for
divorce. Three weeks ago, Mrs. Robinson’s 14 year
old son (her only child) committed suicide on an
inpatient psychiatric mental health unit.in today’s
therapy session, Mrs. Robinson reveals to her nurse
therapist that she is seriously contemplating suicide
herself. What action should the therapist take?
a. Arrange for voluntary hospitalization, if the
patient is willing
b. None, because people who speak of
committing suicide seldom do it
c. Arrange for immediate hospitalization
d. Request permission to speak with the
husband to suggest marriage counseling
13. A young adult client is scheduled for her first
debridement of a second-degree burn of the left
arm. It is most important for the nurse to take which
of the following actions?
a. Assemble all necessary supplies and
medications
b. Plan adequate time for the dressing change
and provide emotional support
c. Prepare the client and family for the pain
the client will experience during and after
the procedure
d. Limit visitation prior to the procedure to
reduce stress
14. The nurse is caring for a 67 years old man following a
cardiac catheterization. Two hours after the
procedure, the nurse checks the patient’s insertion
site in the antecubital space, and the patient
complains that his hand is numb. The nurse should:
a. Change the position of his hand
b. Check his grip strength in both hands
c. Notify the physician
d. Instruct the patient to exercise his fingers
15. A client is to receive 1000mL of IV fluid over 10
hours. The IV tubing set calibration is 15gtt/mL.how
many drops per minute would the nurse give?
a. 125gtt/min
b. 115gtt/min
c. 25gtt/min
d. 100gtt/min

16. Which intervention would the nurse anticipate for a
patient who is diagnosed with osteitisdeformans
(Paget’s disease)?
a. Biphosphate and recommended doses if
calcium and vitamin D
b. Calcitonin and vitamin A supplements
c. Estrogen and physical therapy
d. A low-phosphorus and aerobic exercise

23. A 47 year old woman comes to the outpatient
psychiatric clinic for treatment of a fear of heights.
The nurse knows that phobias include:
a. Projection and displacement
b. Sublimation and internalization
c. Rationalization and intellectualization
d. Reaction formation and symbolization

17. The nurse has just received report from the previous
shift. Which of the following clients should the nurse
see first?
a. A client who is receiving a blood transfusion
and complains of a dry mouth
b. A client who is scheduled to receive heparin
and PTT is 70 seconds
c. A client who is receiving ciprofloxacin
(Cipro) and complains of fine macular rash
d. A client who is receiving IV potassium and
complains of burning at the IV site

24. When teaching a client with myasthenia gravis about
the management of the disease, what advice should
the nurse give to the patient?
a. Prevent structured, active exercises at least
twice a week to prevent muscle atrophy
b. Protect extremities from injury due to
decreased sensory perception
c. Arrange a routine to accommodate frequent
visits to doctor’s office
d. Perform necessary physically demanding
activities in the morning

18. Refer to the following list of drug indications,
actions and side effects. Which statement matches
with simvastatin (Zocor)?
a. Lowers LDL level, increase HDL level, and
slows progression of coronary artery
disease. Adverse effects may include
myopathy, and hepatotoxicity
b. Lowers LDL, triglycerides, and
apolipoprotein B levels by blocking
absorption in the gastrointestinal tract.
Minimal adverse effects have been
identified.
c. Lowers LDL cholesterol and VDL triglyceride
levels; raises HDL. May cause severe
flushing
d. Reduces VLDL and increases HDL levels.
Gastrointestinal disturbances and an
increased risk of gallstones may occur.

25. Client with paranoid thinks he is the son of the US
president. During interaction, he began to have
hallucinations again, which action should be done by
the nurse first?
a. Ignore the hallucinations and proceed with
the interaction
b. Recognize the patient’s anxiety the proceed
with the interaction
c. Let the hallucinations be the center or topic
of the interaction
d. Ask for help

19. A client is admitted with irritable bowel syndrome.
The nurse would anticipate the client’s history to
reflect which of the following?
a. Pattern of alternating diarrhea and
constipation
b. Chronic diarrhea stools occurring 10-12
times per day
c. Diarrhea and vomiting with severe
abdominal distention
d. Bloody stools with increased cramping after
eating
20. The nurse is preparing to do postoperative
assessment on a 5 year old child who has undergone
tonsillectomy. During the assessment, the nurse
should be alert for bleeding. Which signs and
symptoms would indicate active bleeding? (select all
that apply)
a. Drowsiness
b. Dark red vomitus
c. Mouth breathing
d. Frequent swallowing
e. Frequent clearing of throat
21. The nurseis preparing to administer carvedilol
(Coreg) to a patient. Which action should the nurse
take first?
a. Find the results of the patient’s last blood
pressure measurement
b. Check the patency of the patient’s IV line
c. Assess the patient’s current pulse and blood
pressure
d. Review the patient’s urine output as
recorded by nurses on the previous shift.
22. Who to see first?
a. Post colectomy with abdominal cramping
b. Patient with post bone marrow transplant
with diarrhea
c. Patient with cast 30 minutes ago with
muscle spasm
d. Patient chemo with n/v

26. Your patient has been admitted in preterm labor and
is receiving magnesium sulfate as a tocolytic. You
prepare her for the common side effects of this
medication, which include drowsiness, lethargy,
feeling warm and
a. Palpitations
b. Muscular weakness
c. Tremulousness
d. Tachycardia
27. A client has just been admitted after sustaining a
second-degree thermal injury to his right arm. Which
of the following nursing observations is most
important to report to the doctor?
a. Pain around the periphery of the injury
b. Gastric pH less than 6.0
c. Increased edema of the right arm
d. An elevated hematocrit
28. Which drug would the nurse question?
a. Prozac for client with bulimia
b. Seroquel for patient with undifferentiated
schizophrenia
c. Olanzapine for OC
d. Buspar for client with anxiety
29. A patient with Raynaud’s disease should be taught to
avoid which environmental factor?
a. High levels of smog
b. Cold temperature
c. Exposure to secondhand smoke
d. Contact with pesticide
30. Which statement by a 7-year-old client would
indicate an understanding of when to take
medication (via inhaler)?
a. “After one puff, I can immediately give
myself another puff”
b. “I need to depress the top of the inhaler as
I begin to take a breath.”
c. “When I remove the inhaler, I can exhale
through my mouth.”
d. “I need to inhale the medicine and then
hold my breath to the count of 10.”
31. To detect diabetic ketoacidosis (DKA), which of
following would you test for ketones?
a. Plasma

Urinary output of 30mL/h d.” d. the client has complained of increased pain and is less communicative. “Take the medication with a minimal amount of fluid just before bedtime. “Are you taking medication?” 44. Which action by Lucy demonstrates assertive behavior and positive interpersonal relationships? a. The nurse has administered sublingual nitroglycerin (Nitrostat) to a client complaining of chest pain. Blood pressure has decreased from 140/80 to 90/60. The patient is taking ibandronate (Boniva) for the prevention of osteoporosis. The client indicates that the chest pain has subsided. You are caring for a 7-year-old client with a brain tumor.” b. and the nurse overhears the nursing assistant talking with the patient. Peripheral edema 38. Which of the following statements made by the nursing assistant would require immediate intervention by the nurse? a. “You’re going to be moved to private room later today. Manage nutrition and hydration d. d. NPO prior to procedure f. and anorexic. Will stay in hosp for a few days post op 40.” . The client indicates the need to use the bathroom. Responding in kind to a patient who uses abusive language will perpetuate the behavior. “I had a big breakfast this morning.” b. Which of the following nursing goals should be a priority at this time? a. Maintain fluid volume b. It would be most important for the nurse to ask which of the following questions? a. to which goal should the nurse assign the highest priority? a. “Do you have any allergies?” b. The patient becomes angry and uses abusive language with the nurse. The nurse on a psychiatric unit of the hospital refuses to agree to a 32-year-old patient’s request to organize a party on the unit with his friends. Serum sodium of 130 mEq/L b. A patient is hospitalized for severe pregnancyinduced hypertension (PIH).b. No special prep needed e. Recently. “I’ve been taking aspirin for my sore knees. What is the probable cause of this increase? a. Which of the following statements indicates that the nurse has an understanding of the patient’s behavior? a. “Take the medication in the morning with a glass of water and then don’t ingest anything for 30 minutes. Lucy requests that her husband join her weekly sessions to deal with the husband’s use of alcohol and extramarital affair. Verify that the physician has discussed the prognosis with the family 33.” d. Anesthesia will be used d. very irritable. “I’ll stay in the bathroom with you while you take your shower. Abusive language is one the behaviors that is a symptom of the patient’s illness. “Have you been drinking lots of fluids?” c.” c.” 41. A shift of red blood cells from the fetus b. Increased hematopoiesis in the red bone marrow 35. Her hematocrit has increased two points since the previous day.” d. A 20-year-old in traction for multiple fractures of the left lower leg b.” c. b. Relieve client’s anxiety c. Lucy cries for 28 minutes of the 30-minute therapy session c. A nursing assistant is assigned to constant observation of a suicidal patient. Weight loss c. “Let’s put your clothes in the dresser. Lucy is a 34-year-old married woman with chronic low self-esteem. Which of the following client statements should the nurse report to the physician? a. Lucy says to the nurse. No discomfort post-procedure c.” c. An 89-year-old with Alzheimer’s disease awaiting nursing home placement 34. “Take the medication on a full stomach immediately after meal. so I sleep a lot. d. A client is admitted to the neurology unit for a myelogram. Which observation would alert you to the possible development of syndrome of inappropriate antidiuretic hormone secretion (SIADH)? a. Endoscopic Retrograde Choliangopancreatography (ERCP) SATA a. A 60-year old man with a diagnosis of pneumonia is being admitted to the medical/surgical unit. Provide pain assessment and effective pain management c. c. Decreased red blood cell destruction by the spleen d. A 50-year-old recovering alcoholic with cellulitis of the right foot d. “Using lotion has helped my dry skin. Check for gag reflex postprocedure b.” b. 42. b. “Are you wearing any metal objects?” d. d. A client has been diagnosed with metastatic cancer with a poor prognosis. A 35-year-old with recurrent fever of unknown origin c. “I went to the tanning salon yesterday. The nurse is preparing a client for a skin biopsy. The nurse should place the patient in a room with which of the following patients? a. The nurse should model acceptable behavior and language for all patients. b. “I am going to make other people’s lives as miserable as mine is. c. “My husband’s behavior gives me headaches. Respiratory rate has increased from 16 to 24. A shift of fluid from the vascular compartment c. 37.” 36. Encourage client to talk about the possibility of dying. “Take the drug first thing in the morning with a full glass of milk or juice. Control the bleeding 43. Feces Urine Sputum 32. In planning care for a client with cirrhosis who was admitted with bleeding esophagealvarices. Lucy says to the nurse. Maintain airway patency d. Allowing the patient to use abusive language will undermine the authority of the nurse. Which statement should be part of the patient education provided by the nurse? a. c. b.” 39. Which of the following observations is most important for the nurse to report to the next shift? a.

Increased venous return to the heart decrease myocardial oxygen needs. blood pressure 128/68mmHg. The body swings through and beyond the crutches c. Caregiver role restrain c. b. “I will need to take antibiotics for at least a week. The right foot acts like a balance d. Complaints of burning on urination. Which nursing diagnosis would be most appropriate for this patient? a. A pen light c. the nurse observes that the client may be experiencing Cushing’s triad. Anxiety 55.2 mg/dL. heart rate 80beats/min. Blood pressure 150/70mmHg.d. What action should the nurse take when performing intermittent nasogastric (NG) feedings in a client? SATA a. Blood pressure 110/70mmHg. “I’ll be right back with something for you to eat. Give the child an alcohol bath for an elevated temperature b. Fetal monitoring b. respiration 26. RR of 8 d. During the most recent visit to the clinic. 47. Palpate the patient’s fundus c. BUN 7. A safety pin 50. AST (SGOT) 12 U/L. creatinine 0. Aspirate the stomach contents f.3 Arterial pCO2: 60 mmHg Arterial pO2:75 mmHg Arterial HCO3: 35 mEq/L Based of this information which nursing action would be the best action? . One hour after admission. heart rate 122beats/min. On admission.” 45. c. the nurse should instruct the parents to: a. Assess the patient’s level of consciousness 48. and dizziness. Hyperextend the client's neck. respiration 16 d. BP of 90/60 c. Which vital signs are indicative of Cushing’s triad? a. Place an ice bag on the child’s leg for three days d. Check the child’s temperature every four hours for three days 56. Blood pressure 152/88mmHg. Tongue depressor b. 46. Administer antipyretics for discomfort. c. CVP of 30cmH2O 53. The hands and arms support the body’s weight b. d. A patient diagnosed with angina is instructed to rest when having an episode of chest pain. Monitor the patient’s pain d. the patient tells the nurse he lost his job and feels useless because he is unable to provide for the family. d. Check the patient’s lochial flow b. “I will use only prescribed douches to avoid a recurrence.5 mg/dL. The initial nursing assessment should include all of the following except? a. A patient with chronic mental health problems has been making progress with treatment. Asking about the pain c. The nurse is caring for a client with a cervical spinal cord injury. bright red bleeding.6F. however. Which patient is robust? a. b. the client develops stridor on exhalation. “I will avoid using tampons for eight weeks. c. Coronary arteries constrict and shunt blood to vital areas of the myocardium. Keep the head of the bed elevated at 15 degrees b. Deliver the feeding by pushing on the syringe plunger e. 58. “I will return for a Pap smear in six months. Clamp the NG tube once the feeding is complete 54.” b. b.” c. Twelve hours after a total thyroidectomy. and fever c. Which of the following client statements. Pulse pressure of 40 b. Situational low self-esteem d.” d. The client needs instruction regarding how to walk in crutches using a three-point gait prior to be discharged from the Emergency Department. What equipment would be necessary for the nurse to complete an evaluation of cranial nerve III during a physical assessment? a. Social isolation b. Weight bearing is permitted on the left foot g. A balance between myocardial cellular needs and demand is achieved. complaints of fever and chills. d. Taking vital signs d. heart rate 120beats/min. respiration 14 57. A G1P0 30-year-old patient at 38 weeks gestation is admitted with heavy. Advance both crutches and swing both feet forward e. Irrigate the NG tube prior to initiating feeding c. Blood pressure 130/72mmHg. To minimize the side effects of a DPT immunization for a six-month-old. Reassure the client that the voice change is temporary. ALT (SGPT) 14 U/L. What is the best explanation for how rest relieves the pain associated with angina? a. Coronary blood vessels dilate and increase myocardial cell perfusion. What is the nurse’s best first action? a. total bilirubin 0. A 12-year-old client has a right tibia fracture that is casted. Document the finding as the only action. BP 90/60. Which of the following is the first nursing action that should be implemented for a 25-year-old woman after a vaginal delivery? a. Which instructions would be included? (SATA) a. the vital signs of a client with a closed head injury were temperature of 98. respiration 30 b. A vaginal examination 51.2 mg/dL. heart rate 90beats/min. Deliver feedings through a syringe barrel attached to the NG tube d. thirst. Weight bearing is permitted on the right foot f. Vital signs and laboratory results for this client are as follows: Blood pressure: 128/72 mmHg Heart rate: 94 beats/min Arterial pH: 7. Call for emergency assistance. if made to the nurse. A cotton swab d. The nurse is caring for a client receiving amphotericin B (Fungizone) 1mg in 250cc of 5% dextrose in water IV over a 2-hour period. heart rate 110beats/min. irritability. illustrates an understanding of the possible sequelae of this illness? a. 49. A female client is diagnosed with human papillomavirus (HPV). The axillary area supports the body weight 52. respiration 24 c. The nurse should be most concerned if which of the following was observed? a.

From 28-52 weeks b. may take how long? a. temperature 99°F (37. It would be most important for the nurse to ask which of the following questions? a. and purposeless pacing. Used to relieve symptoms associated with benign prostatic hypertrophy b. d. Assess for evidence of bleeding and notify the parents 62. “Are there other children in the family?” b. “Infuse 80 mEq of potassium chloride in 100 cc D5W over 30 minutes. sardines. Document the event on an incident report and notify the physician b. as it will cause muscle breakdown. In the immediate postoperative period. b. “Have your other children had chickenpox?” b. delusions and thought broadcasting. and shrimp in your diet c. 63. Administer the medication 68. the nurse should make which nursing diagnosis? a.3°C). “Does your child have a temperature?” c. A patient diagnosed with gout asks. select the purported use of: Black cohosh (Cimcifugaracemosa) a. Insist the client rest instead of visiting with family b. The nurse has collected the following data: client anger directed toward staff in the form of frequent sarcastic or crude comments. Delusions of reference d. The woman has red nail polish on her fingers and toes. Decrease the amount of liver. Increase the amount of citrus fruits in your diet d. A middle-aged man is admitted to an inpatient psychiatric unit. which of the following nursing assessment is most important? a. Increase in the pulse pressure. The patient take Motrin as needed b. what is the most appropriate action? a. “Is the child current on his immunizations?” 61. The nurse’s aide comes to take a woman by wheelchair for a magnetic resonance imaging (MRI) scan of the head and neck. because she is in preterm labor 66. Powerlessness in hospital situation d. Amount and consistency of sputum. c. Used to improve memory. c. Which plan would be most appropriate? a. The woman removes her dentures and gives them to her husband. It would be most important for the nurse to ask which of the following questions? a. The woman has a nitroglycerine patch on her right chest area. Drink at least 1 to 1. Delusions of persecution b. The incident was discovered 2 hours after administration. “Do you have someone to watch your child?” 64. Monitor the EKG during the medication’s administration c. b. Administer prophylactic antibiotics . Over the last several months he has become convinced that his brother is trying to steal his property. Ineffective individual coping related to recent anger and anxiety 67. The nurse knows that this client is demonstrating which of the following a. Side-lying position b. The nurse receives a phone call from a nursing assistant who states that her five-year-old child has developed chickenpox. Presence of breath sounds bilaterally. Sims position c. d. Which position would be most effective in helping the client breathe? a. A patient who is 28 weeks pregnant complains of lower back pain. but it was administered intravenously instead of subcutaneously. Based on the nurse’s understanding of potassium administration. Switch the administration route to oral d. 69. 60. Up to 3 minutes c. Mr. He is diagnosed with paranoid disorder.a. would require an intervention? a. and encourage coughing and deep breathing Notify the physician. b. Notify the physician. From 2 to 8 weeks 65. The woman’s vital signs are: BP 120/70. inform the physician about the client’s metabolic acidosis and anticipate a sodium bicarbonate continuous infusion Evaluate airway patency. Risk for potential activity intolerance as evidenced by purposeless pacing c. particularly after the client has used the telephone. Order a PTT and INR levels and notify the physican d. Which of the following observations. Trendelenburg position 71. Position of the trachea in the sternal notch. d. A client returns to the unit from the recovery room following a laryngoscopy. c. Hold the next scheduled heparin dose c. and reevaluate the client in 30 minutes Evaluate airway patency. “Is there anything I can do to decrease my uric acid levels?” What is the nurse’s most appropriate response? a. During the nursing history interview. sharpen concentration and promote clear thinking 72.5 liters of fluid each day. Up to 30 minutes d. Command hallucination c. c. Used to relieve depression d. Low fowler’s position d. b. d. For the following herbal supplement. Holloway has just received his first dose of this antipsychotic medication perphenazine (Trilafon) you know that the response time to the medication for cognitive and perceptive symptoms. A 9-year-old client is given his heparin injection on time. What is the highest priority in providing care to a client who is admitted to the hospital with sickle cell crisis? a. Used to relieve symptoms of menopause c. What should the nurse suggest? a. Persecution hallucination 70. An adult patient’s prescription reads as follows. a preschool client’s mother reports that the child has frequent bouts of gastroenteritis. pulse 80. “Does the child attend a day care center?” c. as these are the cause of back pain in pregnancy The patient tell her provider immediately. place the client in high Fowler’s position. Impaired social interaction related to conversion reaction b. “Does the child play with neighborhood children?” d. respirations 12. Contact the prescriber about the order b. request an order for midazolam. such as hallucinations. Based on this data. increased wringing of hands. administer pain medication and encourage coughing and deep breathing 59. “Have you had the chickenpox?” d. Lower back pain is part of being pregnant and there is nothing the patient can do about the pain The patient pay close attention to her body posture and mechanics. if made by the nurse. A client is diagnosed with lung cancer and undergoes a pneumonectomy. Avoid strenuous activity.

An excessive concern over gaining weight and a refusal to maintain a minimally normal body weight. Delusion etiologies b. Anorexia nervosa 85. “I just don’t feel good. It is most important to refer which of the following clients for home care? a. A client with deep vein thrombophlebitis suddenly develops dyspnea. Encourage the client to obtain a permanent breast prosthesis upon discharge from the hospital b. administer no of insulin and contact the physician immediately d. Ask the patient the reason why she doesn’t want to take a bath d. the infant is also drooling. Document refuse to take a bath 75. Mr. QT interval d. Code cart 84. Match the eating disorder with the correct description of the disease. a. Instruct the client to watch the clock and use the PCA pump every 10 minutes c. Acetaminophen (Tylenol) c. A client returns to the unit undergoing a right modified radical mastectomy with dissection of the axillary lymph nodes. Patient with osteoarthritis experiencing joint stiffness 86. Intravenous infusion pump c. ataxia 81. The nurse instructs the nursing assistant to sit with the client while he eats c. Insist that the client examine the surgical incision when the surgical dressings are removed . Patient taking Glucophage with glucose reading of 185mg/dl b. You need to assess him for movement disorders as a side effect of Haldol. Probenecid (Benemid) d. Right 8th intercostal space d. Once a day on an empty stomach d. midclavicular line b. Allen has psychosis and has been treated with haloperidol (Haldol). An 18 month old client is admitted to the hospital with a fever of 104F. aphasia b. rigidity. Hernandez blood sugar is 122. Among the four patients. The nurse is planning discharge for a group of clients. administer no insulin 74. rigidity. What is the nurse’s initial. A client with congestive heart failure who underwent diuresis in the hospital 79. Left 3rd intercostal space. The nurse evaluates the most recent vital signs recorded in the chart 83. Extrapyramidal reactions c. bradykinesia c.” Which of the following actions. Patient who had a spinal injury and is complaining of throbbing headache c. A postoperative cholecystectomy client who is complaining of incisional pain d. What is your intervention? a. d. what will the nurse do? a. Patient diagnosed with seizure who wants to change medication time d. midclavicular line 77. Spasticity. PR interval c. respirations of 56/min.c. The nurse talks with the client about how he is feeling b. suprasternal retractions and a pulse oximeter reading of 85%. Assess the client’s blood pressure and heart rate d. Mr. who warrants immediate attention? a. Once a day before bedtime b. To maintain normalized blood sugars. Tremors. Call two staff nurses to help you bathe the patient b. dysphagia. ST segment elevation b. Which equipment would be important to have at the bedside? a. Autonomic dysreflexia d. What level of activity would the nurse anticipate for the first postoperative day? a. A patient with Alzheimer’s disease doesn’t want to take a bath. Allopurinol (Zyloprim) b. administer 2 unit of insulin b. Biologic rigidity reactions 76. A diabetic client who had a cardiac catheterization in the early AM c. Which drug would the nurse anticipate administering for the treatment of inflammation of acute exacerbations of gout? a. Consume 10-12 glasses of water per day c. Width of QRS complex 82. Bulimia nervosa b. and chest pain. Tracheostomy tray b. Colchicine (novocholchicine) 87. A patient with acute coronary syndrome is administered thrombolytic therapy. A postoperative appendectomy client who is complaining of incisional pain b. Acute epiglottitis is suspected. Once a day with breakfast 80. Attempt to bathe the patient slowly and calmly c. Which instruction would be given to a client who is receiving oral methylprednisolone regarding when and how to take the medication? a. Apply 100% oxygen via face mask b. if taken by the nurse is best? a. Which measure is an appropriate intervention for the nurse to include in the client’s postoperative care? a. Dysarthria. The nursing assistant reports to the nurse that a client who is one-day postoperative after an angioplasty is refusing to eat and states. administer 4 unit of insulin c. Auscultate for abnormal heart sounds 78. The nurse contacts the physician to obtain an order for an antacid d. Obtain a 12-lead ECG c. Identify the location on the chest area where the nurse would take an apical pulse. diplopia. Paresthesia. tachypnea. Left 8th intercostal space c. A patient with osteoarthritis has had hip replacement surgery. Initiate intravenous fluids to maximize hydration Insert urinary catheter to measure accurate output 73. a. Defibrillator d. Hernandez has the following sliding scale insulin prescription: Blood glucose < 130mg/dl: administer 0 unit of insulin Blood glucose 130-160mg/dl: administer 2 unit of insulin Blood glucose 161-190mg/dl: administer 4 unit of insulin Blood glucose 191-220mg/dl: administer 6 unit of insulin Blood glucose 221-250mg/dl: administer 8 unit of insulin Blood glucose >250mg/dl: administer 10 unit of insulin and contact the physician immediately Mr. Which portion of the EKG tracing would the nurse observe to determine the effectiveness of the medication? a. most appropriate action? a. Right 5th intercostal space. What is another name for these movement disorders? a. paresthesia d.

Claudication c. “I am so tired. high fever and hoarseness 101. Decreased erythrocyte sedimentation rate c. Angina 96.5% is given immediately after an infant is born to provide prophylaxis against: a. the nurse makes the following observations: Pulse: 96 Respirations: 28 Blood pressure: 84/62 Child sleeping quietly Which nursing action is most appropriate? a. mumps and rubella vaccines c. red vaginal bleeding with moderate cramps. The triage nurse for a women’s health center receives a phone call from each of the following women. “The pillow is intended to prevent the inadvertent movement of the left leg beyond the body’s midline. 3 ounces of beef d. Administer oxygen until breathing is easier 97. 1 ounce of cream cheese b. Morphine 1 mg IV push has been administered. A thermoneutral environment permits the neonate to maintain a normal core temperature with increased caloric consumption b. The respiratory assessment reveals that the infant has upper airway congestion and slightly labored respirations. Do you think you are dying? 89.” d. Two doses of diphtheria. Neisseria gonorrhoea 92. 88. A 4-year-old has been admitted with second-degree burns and is undergoing debridement of the wounds. The client informs the nurse that he would be more comfortable without the pillow. Chickenpox and smallpox vaccines 99. A primigravida woman who is five weeks gestation and is having vaginal spotting and some cramping. Drooling. Patient with HIV states. Tall peaked T-wave 94. Why are you tired? c. c. Croupy cough. abdominal pain. The nurse is assessing an infant who had a repair of a cleft lip and palate. my life is useless. c. Which food choice would be most appropriate for a patient with osteoporosis who wants to increase calcium intake? a. Irritability. Erythromycin ophthalmic ointment 0. “I should use an over-the-counter antimicrobial ointment. The neonate produces heat by increasing activity and shivering d. coarse crackles bilaterally and low-grade fever d. Retinopathy b. indicates understanding of aseptic technique? a. Prolonged QT interval c. “I should wash my hands before redressing my wound. Shallow. A booster dose of trivalent oral polio vaccine d. if made by the client. “The pillow is intended to prevent the contact of both knees and reduce the risk that pressure ulcers will form. Decreased antistreptolysin-O titer b. the child awakens crying and . “I should keep the wound covered at all times. What is the complication called? a. A six-month-old infant has had all the required immunizations. Which findings will the nurse observe in this patient? a. Elevate head of the bed b.” b. The nurse is aware that which of the following statements.” d.The nursing evaluation of the respiratory status of a 3-year-old client who is newly admitted with acute epiglottitis would indicate the following findings: a.” c. “I need to buy sterile gloves to redress this wound. I am going to die anyway. 1 medium stalked of cooked broccoli c. Which EKG tracing would the nurse recognize as an early indicator of hyperkalemia? a. dull. Position the infant on one side d. Both Neisseria gonorrhoea and chlamydia trachomatis d. A multipara woman who is four weeks pregnant and reporting unilateral. Stroke d. After receiving a total hip replacement. the client returns to the unit with an abductor pillow in place.” c.d.” 90.” b. The nurse knows this would include which of the following? a. decreased pulse and stridor b.” 102. Individuals with diabetes mellitus can have a chronic complication in which there is pain in the lower extremities due to lack of blood supply. Macular rash that is pruritic d. tetanus. Metabolism slows dramatically in the neonate who experiences cold stress c. Syphilis c. What is the nurse’s best response? a. A primipara woman who is seven weeks pregnant and reporting increase in whitish vaginal secretions. Why is maintaining a thermoneutral environment essential for the neonate? a. and pertussis vaccine b. “The pillow is intended to prevent the inadvertent movement of the left leg too far way from the body. During the night. Irritability. 1 medium apple 93. Measles.A client with necrotizing spider bite is to perform his own dressing changes at homes. A thermoneutral environment permits the neonate to maintain a normal core temperature with minimum oxygen consumption 98. Depressed ST segment b. Suction the infant’s mouth and nose c. d.A 22-month-old child is hospitalized for heart failure. b. A 4-year-old child presents with possible rheumatic fever. A multigravida woman who is six weeks pregnant and reporting frank. Refer to support group b. Chlamydia trachomatis b. “The pillow is intended to prevent early ambulation if you should wake up confused. Which woman should be directed to come to the health care facility immediately? a. 91. d. Post a sign at the bedside to avoid pressure measurements or venipunctures in the right arm. Which of the following nursing actions would be most appropriate? a. inverted T wave d. What is the specific cause that makes you feel tired? d. drooling and absence of spontaneous cough c.” a. Allow the child to sleep quietly Administer nalozone (Narcan) Administer 100% oxygen 95. flat. Following administration of this medication. Elevated C-reactive protein levels 100. Keep the code cart at the bedside b.

“We only change the ostomy bag every ten days.00 units via oral swab every 6 hours. A father reports that her bumped the crib of his two-day-old infant and she violently extended her extremities and returned to their previous position. jugular vein distention. Going grocery shopping 115. Fundal and lochial assessment b. The medication should be taken on an empty stomach d.calling for the mother. The client becomes hypertensive and tachycardic d. A 35-year-old admitted 3 hours ago with a gunshot wound. if taken by the nurse. c. if made by the parents of a nine-year-old client with an ostomy. Thrombocytopenia 109. Dim the lights and allow the mother to rock the child to sleep b. A mother reports that the umbilical cord of her five-day-old infant is dry and hard to touch.” b. Decreased fetal movement d. Perform stretching and strengthening exercises d. Confront the patient about his anger and inappropriate plan of action c. Leukopenia b. For which side effects should the nurse assess the client? a. Continue to monitor the client frequently and increase fluid rate c. The client complains of sever leg and arm pain 111. b. Premature closure of the ductusarteriosus 106.A client is being prepared for surgical repair of an abdominal aortic aneurysm. Auscultate lung sounds and suction if needed d. “We change the bag at least once a week and we carefully inspect the stoma at that time. A mother reports that the “soft spot” on the head of her four-day-old infant feels slightly elevated when the baby sleeps.An extremely angry patient with bipolar illness tells the nurse he just learned his wife filed for divorce. A bruit and thrill are palpable at the aneurysm site c. What should the nurse teach the patient to ensure safe use of this medication? a. patient complains of chills 112. Retirement b.Education about health promotion is often effective during periods of role transitions. Wear a lead-lined apron whenever delivering client care 107.Which of the following statements. the respiratory rate is 34. “We encourage our daughter to watch TV while we change her ostomy bag. The nurse assesse the child and notes dyspnea. which action should be taken next? a. b. Moving into a new house in the same neighbourhood d.The nurse is performing discharge teaching on a client with multiple sclerosis. Participate in social activities 110. Allow the patient to use the phone b. Oral thrush c. The nurse notices that the client is restless. The prescriber should be notified if the patient experiences any unusual bruising or bleeding c. Diarrhea d. no drainage noted from the chest tube in the last eight hours d. Restrict visitor who may have an upper respiratory infection b. Which of the following is a role transition? a.The nurse is caring for patients on the surgical floor and has just received report from the previous shift. After the nurse begins oxygen by 40% face mask. Buying a new car c. Vital signs every hour d.” c.Indomethacin is given as a treatment for preterm labor. “We change the bag every day so that we can inspect the stoma and the skin. The nurse suspects complete aortic dissection when: a. Which of the following responses by the most nurse is most appropriate? a. Stay with the child and call for assistance to notify the physician 103. A prothrombin time should be drawn upon initiation of therapy and every 2 months b. Premature closure of the ductusvenosus b. What should the nurse’s first action be? a. Assign only male caregivers to the client c. A 59-year-old with a collapsed lung due to an accident. It is most important for the nurse to include which of the following instructions? a. Avoid overexposure to heat or cold c. Do not allow the patient to use the phone because he is an involuntary patient . Which of the following actions. is most important? a.” d. Place the child in a crib with a blanket and notify the physician d. Ambulation c. Increase the FiO2 setting to 100% c. The client is intubated and on the ventilator at 60% FiO2. 1/5 cm area of dark drainage noted on the dressing. 105.Nursing care in the first 30 minutes after a caesarean section includes: a. would indicate to the nurse that they are providing quality home care? a. Which of the following patients should the nurse see first? a. Enteric-coated tablets should be crushed to make the medication easier to swallow 104. Notify the physician and prepare for immediate surgery 108. Bradycardia c.The nurse is caring for a client with internal radiation. What is a potentially significant fetal side effect of this drug? a. frothy sputum.” 113. A 43-year-old who had mastectomy two days ago. A mother reports that the circumcision of her 3-day-old infant is covered with yellowish exudate. Which of the following messages should the nurse return first? a. Administer pain medication b. Ambulate as tolerated every day b. Plan nursing activities to decrease nurse exposure d.The nurse is caring for a client who sustained severe burns and has an inhalation thermal injury. crackles and pink. A 62-year-old who had an abdominalperineal resection three days ago.A 22-month-old client is receiving Nystatin 200. and he needs to use the phone. 23 cc of serosanguinous fluid noted in the Jackson-Pratt drain c.The nurse is caring for client in the outpatient clinic. d. Oral hydration and nutrition 114.An elderly patient has been prescribed aspirin for osteoarthritis. thrashing. and attempting to cough. The client becomes hypotensive and unresponsive b.

Check the client’s abdominal dressing for any evidence of bleeding d. Fluoxetine (Prozac) c. but I'm getting better. but I don't like to go out much. Keep a linen hamper immediately outside the room b. Uncuffed endotracheal tube d. Set limits on the patient’s phone use because he has been unable to control his behaviour 116. Wear gloves and gown when administering the immunization b. Position the client on her left side." c. Give the patient a meeting schedule for Alcoholic Anonymous b. Prochlorperazine (Compazine) d. Which assessment should the nurse perform immediately? a. Cool. d. “I tire easily when I use my wheelchair just around the house. Which observation would the nurse identify as the desired response for this treatment? a. but I prefer a bed bath. which problem could occur when a patient takes both of these products concurrently? a." 118. Ambu bag 125. which equipment is appropriate for this procedure? (SATA) a." d.A client is receiving plasmapheresis treatments for myasthenia gravis. Monitor the incision and pulmonary status for the presence of infection 127. vomiting. Temperature of 102. b.A client is brought to the emergency room after a motor vehicle accident that resulted in the client sustaining a head injury. "My wife tries to get me to go to the grocery store.To promote safety in the environment of a client with a marked depression of T cells. Increased bleeding potential 117. Face mask f. painful. Obtain a stool sample for culture. supported with pillows b. the nurse should: a. Based in the nurse’s knowledge of drug-drug interactions. and call for an order to obtain a lithium level. Which teaching strategy should be included in the plan? a.Tungen. Use of captioned video materials c. Assessment of short-term memory d.A physician has written an order for an HIV-positive infant to receive an oral polio immunization. Provide masks for anyone entering the room d. Soak in a warm tub twice a day and rub the areas with a washcloth before covering them c. Administer an antidiarrheal medication. c.Mrs. rapid heartbeat. Remove any standing water left in containers or equipment 121.5F c.The nurse observes a client who is taking phenelzine (Nardil) eating another client’s lunch. Auditory or tactile materials d. Decreased immune function c. Increased ptosis b. Restrict eating utensils to spoons made of plastic c. Clean the area carefully with soap and warm water every day and cover them with sterile dressing b. Check the chart and determine the status of the fluid balance from surgery c. thirst.A 19-year-old patient has just been admitted to the detoxification unit after drinking a quart of vodka every day for the past 3 weeks. Elevated blood pressure b. After a few minutes. c. Provision of written information b.A 23-year-old man comes to the AIDS clinic for treatment of large. which of the following activities should the nurse perform next? a. Begin an intravenous drip of D5 ½ NS with 20 mg potassium chloride to infuse at 125 mL/h.A nurse is caring for a client with a spinal cord injury. Assessment of motor function 120. After determining the client’s vital signs. Hold the lithium. moist skin 122. purplish-brown open areas on his right arm and back.The physician informs the nurse that a client needs to be intubated. 129. "I have been using the modified feeding utensils at every meal. deliberate speech pattern 123. d. Heart rate of 52 beats/min b. Use of a slow. I know I would get tired if I tried to leave the house.The nurse is admitting a client to the unit from the postoperative recovery area after abdominal exploratory surgery. Altered renal perfusion d. Administer the immunization as infant is being discharged c. the client complains of headache. and coarsening hand tremors. The nurse anticipates administering which of the following medication? a. Which of the following nursing actions is most appropriate? a.” b. Which observation would indicate this client is exhibiting neurogenic shock? a. Need for frequent rest periods 119. Oral suction e. Clean the lesion twice a day with a diluted solution of povidone-iodine (Betadine) and leave them open to the air 126. Assessment of the respiratory status b. Laryngoscope b. Administer the medication in the same manner as you would to any other infant 128. "I have all the equipment to take a shower. Assessment of pupils c.The nurse is preparing a teaching plan for a patient who is visually impaired. Shower daily using a mild antimicrobial soap from a pump dispenser and leave the lesions uncovered d. What is the most important nursing intervention on the day of admission to reduce the risk of harm to this patient? a. In preparing for the physician to perform the intubation. Administer Librium as prescribed Encourage the patient to attend group therapy sessions Explain the addictive process to the patient 124. nausea. is receiving lithium and outpatient therapy. Buspirone (Buspar) b. Heart rate of 115 beats/min d. Ability to consume an entire meal d. Decreased functional residual capacity c. Sterile gloves c. Nifedipine (Procardia) . and begins to vomit.She now complains of diarrhea. The nurse should instruct the client to: a.A patient’s medicinal history includes the use of the herbal medication garlic and the prescribed medication warfarin (Coumadin). I still have spills. because it is easier. who has been diagnosed with bipolar disorder.d. Call the physician and discuss the rationale for the immunization d. What should the nurse's first intervention be? a.Which statement by a patient would indicate that the patient is adapting well to changes in functional status after experiencing a spinal cord injury? a.

6 134.3. What is the nurse’s best first action? 144.6 c.4. Temperature of 97.5. Administer naloxone (Narcan) as prescribed d. has been prescribed Mucinex (guaifenesin) 300 mg orally daily as part of his treatment for bronchitis. Blood leaking around the chest tube insertion site b.4.A client is admitted in sickle cell crisis and is receiving IV morphine by PCA pump.5 tablet d. Which nursing action has the greatest priority? a. 135. gloves. The pharmacy sends up Mucinex 600-mg extended-release tablets. The child re-enacts the funeral using his stuff toys and pets c. Keep the code cart at the bedside 137. A teenager diagnosed with toxic shock syndrome d. and complains of insomnia and fine tremors of the hands. 0.An autoimmune disorder attacks the myelin sheaths of nerve fibers in the central nervous system and produces lesions called plaques. Car oil change 5. A teenager diagnosed with rubella (German measles) 136. The child asks when he can play with grandpa just after visiting his grave d. When he comes to the pill line in the hospital.6 b. Hygiene 139. Bathing 2.2. stat 141. The child states that his grandpa is just sleeping and would wake up soon 140. The reason the patient is receiving this medication. Mr.A nasogastric tube is ordered to be placed in a client. unable to sit.Mr. An infant diagnosed with respiratory syncytial virus b. Flank pain f. the patient is restless. This statement describes the pathophysiology of which disease? . A young child with a wound infected with S. How many tablets doo you give Mr.An infant born with spina bifida and is scheduled for surgery the next day. and secure the tube a. d. c. Assess the optic chiasm using an ophthalmoscope d. It is most important for the nurse to have which of the following item available? a. Tightness in chest b. Lubricate the tube 2. Advance the tube downward and backward 5.5. Absence of breath sounds on the right side d. 3. Obtain pulmonary function test. The nurse makes the following observations: Pulse: 73 Respirations: 6 Blood pressure: 112/72 mmHg Client is quietly sleeping Which nursing action is most appropriate? a.2.5. Check the position of the tube. Administer 100% oxygen c. A side effect of the medication that will disappear as time passes. Sluggish capillary refill 133. Lawrence? a.Select all self-care activities that persons should be able to perform prior to discharge to home. Red or black urine c. When the nurse checks on the patient. Bubbling in the suction chamber a.Your patient. 143. Place the client in a high Fowler’s position 4. Dilated pupils bilaterally d.When to know if a 6 year old child has a dysfunctional grieving after the death of a grandparent? a. Bilateral crackles 142. Lawrence. What should your first nursing intervention be? a. cuddle and feed the infant c. IV monitor d. the client informs the nurse that she is experiencing numbness and tingling around her mouth.2. (SATA) 1. Insert the tube along the base of the nose 6. Cardiac monitor c.1.6 d.4.6F e. Preventing infection by supine positioning b. Palpable carotid pulse c.The nurse is caring for a client admitted with acute hypoparathyroidism. Pink mucous membranes b. Constant bubbling in the water seal chamber c. he reports that he has taken 2 days worth of the medication as prescribed and is now experiencing dizziness. Which finding would indicate that the chest drainage system is functioning effectively? a.On the second day after a subtotal thyroidectomy. Obtain a complete blood count and serum ammonia level as prescribed b.130. Koo is prescribed chlorpromazine (Thorazine) as an antipsychotic medication. 2 tablets b. 1 tablet. The nurse identifies which of the following as the best explanation about why these symptoms are occurring? a. Heating pad 132. Measure the tube for approximate placement length 3. Extrapyramidal side effects resulting from this medication. The nurse determines that the precautions are correct if the student nurse is caring for which of the following clients? a. Which finding on assessment would indicate a possible haemolytic reaction? (SATA) a. Promoting range-if-motion exercises d. c. Notify the physician Order a thyroid-stimulating hormone level Loosen the neck dressing Offer mouth care 138. Encouraging the parents to hold.The nurse is supervising the staff caring for clients on the medical/surgical unit. None c.1. b.3.4. 2. 3.5. Preventing rupture of the meningocele sac 131. aureus c. and a mask. Allow the client to sleep quietly b. Tracheostomy set b.1. 1. Banking 3.A client has been receiving chlorpromazine hydrochloride (Thorazine). The nurse observes the student nurse enter wearing a gown. The child refuses to eat and stays in his room b. An indication that the dosage of the medication needs to be increased. Organize the following steps in chronological order as they relate to this procedure: 1. Grooming 6. Assess blood pressure with the patient In both the lying and standing positions c.A client has a right-side pneumothorax and a chest tube has been inserted.A 9-year-old client is receiving one unit of packed red blood cells.Which assessment finding indicates effective chest compressions during CPR? a. d. None. Shaking d. Dressing 4. b.

Sluggish capillary refill and hypotension c.Lamotrigine is given to clients to relieve them from what? a. Confirm that all staff members understand and comply with the treatment plan.The nurse is teaching a client how to perform selfmonitoring blood glucose (SMBG) using a blood glucose monitor. Perform hygiene care for the old woman 154.A 19-month old child weighs 22 pounds and has an order of 200 mcg digoxin to be given intravenously. Which of the following recommendations. The client sticks her finger on the side of the distal pharynx c. 146. c.e. Langley has hyperosmolar nonketotic coma with hyperglycemia. “The medication helps to maintain coronary blood flow by decreasing platelet aggregation in the coronary arteries.a. Slight pallor and tires easily while crying d. What is most likely source of this dysfunction? a. 0.A bipolar patient refuses to put down the mop that he is swinging to threaten other patients and staff. “Aspirin is used as prophylactic analgesic to reduce pain. Ensure that the potent reinforcers (rewards) are important to the client. steamed vegetables with butter and a cup of coffee 153. Urinary output of 200 ml over 8 hours 158. Measles 148.1mg/ml. The patient is harmful to others 157. Joint stiffness c. 2. Decreased sensation in the extremities d.The nurse is supervising a care given to clients on a medical/surgical unit. What should you do? a. and a glass of iced tea Grilled cheese sandwich. Call the abuse center for the elderly d. Take a ten-minute with his wife around the block 152. You have a vial of digoxin at a concentration of 0. Fever d. Which symptoms would the nurse most likely find on assessment? a. Which of the following findings warrants a call to the physician? a. Cellular fluid loss c. Adrenal gland tumor b.22 mL b. Bleeding d. The client lets her hand dangle before sticking her finger with the lancet b. baked potato with margarine and chives and skim milk Two eggs. Roasted chicken breast. two slices of toast with margarine and a glass of whole milk Baked fish. Fluid retention c. Which side effects should the nurse monitor the patient for? a. if performed by the client indicates to the nurse the need for further teaching? a. What information is most important for the nurse to consider before administering a PRN IM dose of lorazepam (Ativan)? a. face. d. OPV d.” d. and upper extremities.A patient has a subcutaneous terbutaline (Brethine) pump for treatment of preterm labor. Advise the woman to visit the hospital b. b. steamed broccoli with salt and pepper.The nurse is caring for a patient with acute coronary syndrome who is receiving altaplase (tPA).” b. will be most therapeutic to achieve this goal? a. Take a day trip with a friend b.2mL 159. c. The client touches the strip with a large drop of blood from her fingertip d. Hepatitis b. Migraine 151. Tachycardia and flushing 149. Establish mutually agreed upon.A client is admitted to the burn unit with a thirddegree burn to the chest.. Fetal movements are more than 12 per hour 155. which assessment findings should the nurse report immediately? a. The patient is psychotic c.One of the goals the nurse and a client with posttraumatic stress disorder (PTSD) mutually agreed upon is that he will increase his participation in outof-the apartment activities. 0. What is the nurse’s best response? a.5 million/mm3. Take an eleven-minute bus ride alone c. realistic goals. Which of the following nursing actions is of primary importance during this time? a.Which immunization should be withheld if patient experiences seizures? a. During the acute phase (i. The patient feels nervous and jittery c.0 mL d. Which of the following actions. how many millilitres of the solution will you need to deliver the ordered dose? a. Projectile vomiting after oral bottle feeding b. b. “Aspirin is used to prevent fever associated with the inflammatory response in myocardial infarction. Blood pressure d. c. Talk to the child of the old woman c. 0. The client milks her finger after sticking it 156. Hypoxia 160. Muscle pain 150. first 48 hours) of a major burn injury. if made by nurse. A complete blood count reveals a haemoglobin of 8. Fetal movements are fewer than 12 per hour b. the patient asks the nurse why aspirin has been prescribed daily. “The medication increases the amount of blood in the coronary arteries. Temperature of 100F b. She begins to experience CNS dysfunction. Seizure b.6mg/dl and erythrocyte count of 2.Mrs. Hepatomegaly b. Amyotrophic lateral sclerosis Multiple sclerosis Alzheimer’s disease Myasthenia gravis 145.The client is at risk for bleeding related to the Vitamin K deficiency and the altered liver functions a. A restrictive intervention failed d.002 mL c.When completing discharge teaching for a patient who has experienced a myocardial infarction. the nurse saw an old woman filthy and unkempt in her child’s house.” 147. Establish a fixed interval schedule for reinforcement.” c. The patient’s pulse is 124 beats per minute d.The multipdisciplinary team decides to implement behaviour modification with a client. DPT c.During a home visit. d. b. d.A 2-month-old infant is 2 days postoperative tracheoesophageal fistula repair. Edema of hands c. Join a support group and participate in a victim assistance organization d. The nurse should intervene if which of the following is observed? . The patient is harmful to himself b.

After evaluating the results.Which statement by a patient with a history of major depression indicates that he is not maintaining good health in his current environment? a. Which statement if made by the parents would indicate an understanding of the teaching? a.” 171.” 165.The home health nurse is performing a follow-up visit for a 76-year-old man receiving isoniazid (INH) 200 mg every day for 6 months.” b. and discomfort in the suprapubic area.The nurse is obtaining a history on a client just admitted to the unit. “It is important for the child to rest in bed until the symptoms subside. Administering oxygen via face mask c. “I’ll share any information you give me with staff members only. it’s not bad.” c. “We can keep the information just between the two of us. To trigger breast milk letdown To prevent seizures 168. it’s okay.To help prevent polypharmacy interactions in a client who is taking multiple prescriptions. No WBCs or RBCs reported d. urinary frequency. Preventing future antigen exposure 170. “I just don’t like going to the movies like I did before.” c. RBC’spresent c.The client is to have EMG.” c. “Going back to work. Put the patient on NPO 6-8 hours d.” c.” b.” d. 161. which of the following should be a priority in the nursing are plan? a. c. b.Indicated use of magnesium sulphate in pregnancy is: a. “It is important to increase activity prior to insulin administration. A CVP reading of 12 and bradycardia b. “I think I had a migraine yesterday.” 163. Inspects the staff member’s head for louse and nits b.After abdominal surgery. One hour later. The nurse would be most concerned if the client made which of the following statements? a. Instruct the staff member about how to use Kwell 175. Barbiturates d. Which of the following is the correct instruction? a. This is a normal fetal heart pattern 162. Acidosis d. Tachycardia and hypotension c. Administer an antibiotic b.” d. “My hands and feet tingle. Inform a family member of the names and uses of all medications . This could be a sign of uterine rupture b. Rales and tachycardia 173. “It is important to decrease the amount of long-acting insulin. Narcotics 164. Marijuana c. Use a dispensing system as a reminder to take medications on a schedule b. Maintain the client in a supine position b. Ask the client for allergies to seafoods b.Which action would be the first priority when caring for a client in anaphylaxis? a. The nurse would be most concerned by which of the following? a.The nurse knows that which of the following mood altering drugs is most often associated with an increased risk for HIV infection related to intravenous drug use? a. Both prohibit preterm labor and prevent seizure c. d. Request that the staff member contact the physician d.What is the cause of blindness due to diabetic retinopathy? a. Negative glucose b. Ask the patient to empty the bladder 167. Haemorrhage b. d. “I can’t wait to go to my son’s wedding next weekend.” d. a client is admitted from the recovery room with intravenous fluid infusing at 100cc/hr. A nurse and client wear masks during a dressing change for the central catheter used for total parenteral nutrition A nurse injects insulin through a singlelumen percutaneous central catheter for client receiving total parenteral nutrition A nurse applies lip balm to his/ her lips immediately after performing a blood draw to obtain specimen A nurse wears a disposable particulate respirator when administering rifampicin to a client withtuberculosis. Prepare the client for emergency surgery d. Scar tissue 174.A patient is in 8 cm dilated. Specific gravity 1. This could be a sign of cord prolapse c. Dyspnea and oliguria d.A 7-year-old child is diagnosed with insulindependent diabetes mellitus. Obtaining vascular access d. It is most important for the nurse to take which of the following actions? a. “My legs and knees hurt.a.” b.” d. the nurse finds the clamp wide open and notes that the client has received 850cc. “I have blurred vision at times. “If the information you share is important to your care.” b. To prohibit preterm labor b. Notify the client’s next of kin c.The nurse is caring for a client with perforated bowel secondary to bowel obstruction. the nurse should order a repeat urinalysis based on which of the following findings? a. Remove the nasogastric tube 169. Tell the patient that he may experience discomfort because of the needles to be used c. It will be nice to have the whole family together. It was fun. At the time the diagnosis is made.” 172. “I had a great trip to the Smokey Mountains. Inform the staff member that he cannot care for clients until further notice c. Benzodiazepines b. I’ll need to share it with the staff. the fetal heart rate decelerates in the 60s. This is a normal fetal heart pattern d. “It is important for the child to eat 4-6 lifesavers candies or drink orange juice. The client informs the nurse that any information shared with the nurse during the interview is to remain confidential. The child and parents are being taught what should occur if the child presents with signs and symptoms of hypoglycaemia. what instruction would the nurse give to the client? a. Immediately thereafter. “I have an obligation to maintain nurse/patient confidentiality about anything you tell me. 90% effaced and -3 station when her water breaks.018 166. Tiny lesions in the tear ducts c.A urinalysis has been obtained on a client who has been complaining of dysuria.A staff member informs the nurse that his six-yearold child has head lice. Which of the following responses by the nurse is best? a. well. the nurse knows: a.

A client underwent a cerebral angiogram through the right femoral site. Establish unresponsiveness d.An adult client is brought into the Emergency Deparment in cardiac arrest. Determine if the nasogastric tube is patent and draining d. Wash hands. Severe depression with suicide ideation c. Mnemonic disturbance d. Start cardiopulmonary resuscitation b. Cardiopulmonary resuscitation (CPR) is being performed. Document the findings in the chart b.Which factor may contribute to the development of osteoarthritis? SATA a. The client complains of nausea. Wash the burn with soap and water to remove the oil 183. Obesity d. Serum phosphorus level of 5. Name the area where the pulse should be checked.A 7-year-old client is scheduled for a cardiac catheterization. a patient is diagnosed with metastatic liver cancer d. After diagnostic testing. Irrigate the nasogastric tube with normal saline c.The clinic nurse observes that a ten-year-old child with leukemia has a large bum on her arm and the bum appears to be oily. including supplements and herbal remedies to the doctor’s appointment Abstain from taking any over-the-counter medications in addition to the medication you are already taking 176. Equal. d. When irrigating the draining wound with a sterile saline solution. a. Which priority nursing assessment finding to report to the physician? a. Right pedal pulse weaker than left pedal pulse f. Which assessments will the nurse make with this client? a. The child insists on taking a stuffed teddy bear to the procedure c. Peripheral edema Urinary output of greater than 200mL/hr Serum sodium of 150 mEq/L 184.2mg/dL 180. Pulse 122 e. Weight gain b. The child points to the area producing the pain c. The child sleeps soundly. What is the first action the nurse should take in assisting this client? a.c. Intact dressing that needs reinforcement due to bloody drainage 186.The nurse is making a home visit for a client with an abdominal wound. wash hands and remove the soiled dressing b. Family history of osteoarthritis 187. Excessive use of alcohol b. Positive Chvostek’s sign d. Ulnar or radial pulse b. Alert the physician on call 182. Aphasia c. Which assessment finding would indicate that the infant was experiencing pain? a. Amiodarone 400 mg IV push 190. c.The nurse is administering furosemide (Lasix) to a patient who has edema associated with congestive . Administer the PRN pain medication and an antiemetic b. The child has a rating of 6 on the Faces Pain Rating Scale d. Serum calcium level of 6. Teach the client that oil holds germs and makes infection more likely d. Blood pressure of 88/52 mmHg d. Which observation would alert the nurse to the possible development of diabetes insipidus (DI)? a. 20 to 20 years of age c.A 6-month-old infant has returned to the unit from surgery.A client has a nasogastric tube in place after extensive abdominal surgery. bilateral radial pulse b. Prepare the sterile field.Which emergency medication should the nurse initially administer to a client in pulseless electrical activity? a.0mg IV push d. Pour the solution. The child has diminished palpable pedal pulses bilaterally 177. Dorsalispedis pulse c. The child cries steadily and kicks b. Bring all medications. Nephrolithiasis b. Brachial pulse d. d. Patient with bipolar manic phase 179. Regular strenuous exercise f. put on sterile gloves. The first nursing action should be to: a. The client states that she touched a hot pan and her mother put cooking fat on it so it would not blister. Bilateral pink. Epinephrine 1. with an increased pulse rate and decreased blood pressure 178. Respiration 22 g. The child has an allergic reaction of hives to shellfish b. Check the placement of the nasogastric tube by auscultation 189.8 mg/dL c.In which situation is the patient most likely to experience anticipatory grieving? a.A client presents with hypoparathyroidism. Perseveration b. Caucasian or Asian ethnicity e. Psychotic patient with delusion b. A patient finds out that her symptoms were from an ectopic pregnancy 181.The nurse knows which of the following would have the greatest impact on an elderly client’s ability to complete activities of daily living (ADLs)? a. The patient experiences traumatic amputation of an extremity in an industrial accident b. The child has cool lower extremities with brisk capillary refill bilaterally d. His abdomen is distended and there are no bowel sounds. The nurse should: a.Which of the following would the nurse see first? a. prepare the sterile field and remove soiled dressing c. Atropine 1.The nurse is caring for a client postoperatively following removal of a pituitary tumor. Patient with anxiety who is agitated d. Call the physician immediately to report the injury c. flush the wound and wash hands 185. Carotid pulse 188. Check the patient’s airway c.A nurse notices ventricular tachycardia on the cardiac monitor at the nurse’s station and goes to the client’s room. and remove the soiled dressing d. Lidocaine 4mg/min IV infusion b. Which post-procedural nursing assessments would justify calling the physician? (SATA) a.0mg IV push c. warm toes c. A patient is brought into the Emergency Room and declared brain dead c. Remove the soiled dressing. Apraxia 191. which of the following sequences would be most appropriate for the nurse to follow? a.

Laboratory tests indicate the serum sodium is 150 mEq/L and Hct is 48%. “Tell me what occurred first.You are teaching a patient who is newly diagnosed with diabetes. It is most important for the nurse to do which of the following? a.A 30-year-old woman is admitted to the hospital with dry mucous membranes and decreased skin turgor.heart failure. Child with compound fracture on the right femur and massive laceration of the left arm . Abdominal girth measurement 192. Obtain a sputum container for the client to use c. the woman’s vital signs are BP 120/70. Ice cream c. c. d. Quickly rub a cotton swab over both tonsillar areas and the posterior pharynx b.Which measures should the nursing care of a client with hypothyroidism include? a. “How do you feel when you take the medication?” b. 1 ½ inch needle to administer the drug b. Providing cool environment c. temperature 101F (38.5-1 mg c. 12 mL 198. 10-50 mg d. Encouraging the use of heating pad d. high-protein diet 197.The nurse is drawing up a vitamin K injection for a newborn. “You’ve been upset about your blood pressure.Which of the following condition are associated with impaired glucose tolerance (IGT)? a. “What time do you take your medication?” d.45% NaCl c. 0. Planning frequent rest periods b. Buttered popcorn d.A patient undergoing hip replacement surgery who is at risk for the development of deep vein thrombosis is receiving dalteparin (Fragmin). A middle-aged male with elevated temperature and chronic pancreatitis c. D5NSS b. Of the following foods. A young female with recent ileostomy due to ulcerative colitis b. Obesity and syndrome X d. respirations 14. Chocolate chip cookies with nuts b. Obesity and hypotension c. The nurse would identify which of the following patients as a likely candidate for developing acute renal failure? a.3C). Hypoglycaemia and prostatitis b. Serum potassium level c. Which statement correctly describes the administration technique for the medication? a. Irrigate with warm saline and then swab the pharynx d. Use an 18-guage. Lactated Ringer’s 193. Urine specific gravity b.The clinic nurse is obtaining a throat culture from a client with pharyngitis. Inject the medication into the muscle within 2 inches of the umbilicus Aspirate prior to administering the medication Administer the medication by subcutaneous route 200.” 199. The nurse expect the physician to order which of the following IV fluids? a. A teenager in hypovolemic shock following a crushing injury to the chest d. 0. Provide a low-calorie. Baked chips and salsa 195. Hyperextend the client’s head and neck for the procedure 196.did your symptoms occur before or after you took the medication?” c. pulse 88. which is the best choice for your patient? a. Hypotension and hyperlipidemia 194.The nurse is caring for patients in an acute renal care facility.Which statement by a nurse in response to a patient would be an example of a reflective question or comment? a. Daily weight d. What should the dose be? a.9% NaCl d. 1-2 mg b. 0. What is the most appropriate parameter for the nurse to monitor regarding effectiveness of this drug? a. how to choose healthy snacks.

D. and muscle atrophy does not occur because muscles are used during part of the day. and vomiting of dark blood are indications of possible bleeding. Early signs of lithium toxicity are Fine tremors. 3. C. This risk is exacerbated by the betrayal of her husband and best friend. Wheezing results from constricted airways such as in asthma. 24. Late signs include Ataxia. seizures 7. A. Patients are encourage to have frequent rest periods. burning. B. surgery. Fine macular rash during ciprofloxacin administration indicates hypersensitivity reaction. yellowing of the skin and eyes (jaundice). 9. Other symptoms include nausea. Bronchovesicular breath sounds are normal lung sound. the nurse should assess the patient’s current pulse and blood pressure before administering carvedilol. 8. B. swelling. Options B&D are symptoms of hyperthyroidism. It is state of hypermetabolism. decreased urinary output. 5. which is a hormone that contracts the uterus. Hematochezia (red or maroon blood in the stool) is usually due to lower GI bleeding. depressed deep tendon reflexes. Benadryl is an H-1 receptor antagonist and antihistamine with anticholinergic activity and does not protect against vagal bradycardia. 18. However. 23. coldness. A. Magnesium sulfate is a central bervous system depressant and relaxes smooth muscles. The prescriber should be contacted if bradycardia or hypotension is identified prior to administration of the drug. E. 2. Beta2 receptors blockade can result in bronchoconstriction and inhibition of glycogenolysis. Option D. nausea. weight loss. vomiting. The increased metabolic rate generates heat and produces tachycardia and fine muscle tremors. F. . Because of this drug’s effect on the heart. E. Compulsive behavior is an unconscious attempt to control and/or relieve the tension and anxiety the client is experiencing It is not a manipulation on the client’s part. This can spread over the entire body. clearing of the throat. diarrhea. confusion. Muscles are generally strongest in the morning. 26. pharmacological therapy using either bisphosphonates or calcitonin. contractility and velocity of impulse conduction in the atrioventricular node. B. B. D. A. 20. Options B & C refer to inflammatory bowel disease such as ulcerative colitis or Crohn's disease. and are advised to avoid strenuous physical activity. Hyperresonance results from percussing an excessively air-filled lung or pleural space. C. C. and Prozac is a antidepressant. Consolidation will result in diminished breath sounds over the lobes involved. should decrease rate to prevent irritation of the vein. 16. being seen with as little as 50 mL of blood. 11. The presence of frankly bloody emesis (hematemesis) suggests moderate to severe bleeding that may be ongoing. hypotension. loss of appetite. vomiting. * 25. C. whereas coffee-ground emesis suggests more limited bleeding. C. Carvedilol is a nonselective beta-adrenergic antagonist that blocks the action of beta1 receptors in the heart and the action of beta2 receptors in the lung. There is no decrease in sensation with MG. D. pallor. Graves’ disease results from an increased production of thyroid hormone. which can occur in hyperkalemia. Infant suckling cause the posterior pituitary to release oxytocin. PTT is within normal limits. should give medication. Carvedilol is administered orally. Option C are symptoms of hypothyroidism (myxedema). Atropine has a vagolytic effect as well as blocks muscarinic responses and has selective depression of central nervous system. 4. smooth and skeletal muscles. extreme muscle weakness. pain management using analgesics. Melena may be seen with variable degrees of blood loss. B. pulmonary edema and elevated serum magnesium levels. tingling. 19. 10. tachycardia. D. 12. Option B. 21. and nonpharmacological therapy (focusing mainly on physical therapy as a means of improving muscle strength to help control some types of pain). C. C. radioactive iodine. Blocking the beta1 receptor leads to deacreased heart rate. D. 6. 17. which is typically associated with orthostatic hypotension. diarrhea (watery and sometimes bloody). ANSWER 1. Clots or fresh blood in the nose or throat. Condition is often called spastic bowel disease. ECG changes can indicate potentially lethal arrhythmias such as ventricular fibrillation. A. should stop medication and notify the physician. Check the back of the patient's throat with a flashlight for trickling of blood. it can occur with massive upper GI bleeding.14. Notify the if there is arm or hand numbness. Bloody stools do not occur. C. frequent swallowing. Option A does not warrants an immediate concern. or surgical removal of a portion of the gland. or pain 15. A. stomach cramps. A. 22. depressed respirations. A. 13. Adrenalin is a catecholamine that constricts bronchioles and inhibits histamine release. and redness of the skin on the palms and soles. B. Management include the use of antithyroid drugs (propylthiouracil or Tapazole). Client is not subject to depression but to high levels of anxiety. The suicide of her son puts this patient at high risk of suicide. abdominal (belly) pain. and activities involving muscle activity should be scheduled then. Adverse effects include flushing. Decreased BP. C. Four main methods of treatment exist for a patient with Paget’s disease. First signs of acute rejection are usually a rash. and restlessness are hallmark signs of hemorrhage and should be reported to the surgeon immediately.

and a sufficient amount of time between puffs to provide an adequate amount of inhalation medication. usually caused by obstruction resulting from edema. Dye is injected into subarachnoid space before an x-ray of spinal cord and vertebral column to assist in identifying spinal lesions. lethargy is expected. This patient has experienced a loss (job) that is contributing to his feelings of uselessness to his family. B. C. 32. this may be a nursing action. which include fever. Raynaud’s disease is characterized by attacks of vasospasms in the small arteries and arterioles of the fingers and sometimes the toes. 53. An endoscopic retrograde cholangiopancreatography is anendoscopic test that provides radiographic visualization of the bile and pancreatic ducts. B. The pathology behind PIH is a fluid shift that occurs from the vasculature to the tissues. 36. A. The disease primarily affects young women and can be triggered by exposure to cold. B. All other options reveal abnormal assessment. 50. A. SIADH is a condition in which the client has excessive levels of antidiuretic hormone (ADH) and can’t excrete the diluted urine. D. 55. and slowed respirations. holding the breath for 10 seconds or as long as possible to disperse the medication into the lungs.2 mg/dL. C. A local anesthetic is sprayed into the client’s throat. Client is under constant observation. B. Option A & D. Fluoxetine (Prozac) and other SSRIs are given to patients with bulimia nervosa. Amphotericin B causes renal and liver toxicity.6–1. 43. Antibiotics are not used for viral infections. Key treatments for obsessive-compulsive are benzodiazepines and SSRIs. 28. creatine 0. A. B. bilirubin 0. 31. A. Cushing's triad is systolic hypertension with a widening pulse pressure. 59. A. 33. this is a physician function. 49. 52. bradycardia with a full and bounding pulse. Instruct the client to report any signs and symptoms of gastric reflex or pain. Robust means strong and healthy. The client should be monitored for signs of cholangitis and perforation. It should be taken in the morning on an empty stomach with large glass of water (6-8oz) and wait at last 30 minutes before eating or lying down. C. deep breaths to ensure that medication is distributed into the lungs. E. 38.0 mg/dL . F. C. This disorder causes a dilutional hyponatremia. Seroquel is an atypical antipsychotic. Option A & D do not pose a problem or solution regarding gastroenteritis. Stridor on exhalation is a hallmark of respiratory distress. C. in other settings. consequently. F. In some settings. 54. shaking up the medication in the MDI before use. Utilization of an MDI requires coordination between activation and inspiration. The diagnosis of situational low self-esteem is the most appropriate diagnosis for this patient. B. notify the physician if elevated. Option C are not side effects of the medication. A. 60. . Make sure the client has adequate intake of Vitamin D. D. B. The airway is compromised by the bleeding in the esophagus and aspiration easily occurs. there is a major safety issue. Ibandronate (Boniva) is a bisphosphonate drug. AST (formerly SGOT) 8–20 U/L. Pulse pressure of 40 is normal. Environments with increased numbers of children (day care) more likely to promote infections due to close living conditions and increased likelihood of disease transmission. 58. but not as likely as a day care center. B. 30. 56. 51. 40. B. Buspar is an anxiolytic drug. B. D. Antipyretics relieve the combination of side effects. It is important that client drink extra fluids AFTER the test to replace CSF lost during test and to flush out the dye. it should not be chewed. C. 37. hypotension and tachycardia. 47. One emergency measure is to remove the surgical clips to relieve the pressure. Option C is appropriate for MRI. 41. Douches will not prevent recurrence of the disease. Check liver and renal function studies weekly. abdominal pain (especially in the RUQ). Therefore. 29.1–1. the client retains fluids. C. Neighbourhood is a possible source of infection. D. Ice bag is dangerous to both skin integrity and overall temperature control. 46. A.27. E. The North American Nursing Diagnosis Association (NANDA) definition for the nursing diagnosis is the development of a negative perception of self-worth in response to a current situation. C. B. C. Stress ulcers or Curling's ulcers are acute ulcerations of the stomach or duodenum that form following the burn injury. 39. Option D is unnecessary unless indicated for another reason. 34. and it is a neurologic emergency because decompensation is imminent. Several strains of the human papillomavirus (HPV) are associated with cervical cancer. reveals normal values: BUN 7–18 mg/dL. The rise in blood pressure is an attempt to maintain cerebral perfusion. Emergency intubation also may be necessary. C. 42. 57. The client probably received sedating medication before the procedure. A. 48. 44. so it is possible that the gag and cough reflexes will not be present. Postprocedural care after the ERCP include monitoring the vital signs and maintaining an NPO status until the gag reflex returns. In giving such drugs the nurse should instruct the client to swallow the whole tablet. C. if client is allergic to dye. Tampons would not be a problem as in toxic shock syndrome. ALT (formerly SGPT) 8–20 U/L. must not be left alone for any reason 45. D. which causes edema and leads to an increase in hematocrit. C. Olanzapine (Zyprexa) is an atypical antipsychotic drug given to patients with schizophrenia. 35.

breath sounds will be absent. Option C is symptomatic of threatened abortion. A. Fluid administration also helps overcome dehydration. EKG changes in hyperkalemia: Peaked T waves. Permanent breast prostheses are usually obtained about 6 weeks after surgery. MMR is given at 15 months. 66. 68. Ectopic pregnancy needs more emergent intervention as compared to abortion. D. Nitroglycerin patch should be removed before the test. B. 78. Option D symptoms suggest of spontaneous abortion and should be instruct client to pads. Sputum is important to observe but not as high a priority. but this redness will eventually disappear. ECG monitoring of acute coronary syndrome: features that increase the likelihood of infarction are: new ST-segment elevation. .g. 94. A. An abduction pillow may also be used to keep the legs shoulder width apart and to prevent rotation of the hips. During a sickle cell crisis. Instillation of erythromycin into the neonate’s eyes provides prophylaxis for opyhalmia neonatorum or neonatal blindness caused by gonorrhoea in the mother. results are within normal limits. the idea that his brother is trying to steal his property is not validated by reality. 97. A. C. D. 71. Flat P waves 76. 84. Delusion of perseceution is a strongly held belief that is not validated bu reality. C. Polio is given at two and four months and again at 12 to 18 months. Widened QRS complexes. Potassium chloride must be diluted and administered at a rate no faster than 20mEq/hr 69. increasing the transport and availability of oxygen to the body's tissues is paramount. an increase in pressure could occur on the operative side and could cause pressure against the mediastinal area. 74. Erythromycin is also eefctive in the prevention of infection and conjunctivitis from Chlamydia trachomatis. D. 67. A. D. Smallpox vaccine is no longer recommended. B. Among the 4 women. a possible predisposing factor common in clients with sickle cell crisis. 70. 73. Other features of ischaemia are ST-segment depression and T-wave inversion. Pulse pressure does not relate to the situation 63. 96. the least stable patient is the patient experiencing unilateral dull abdominal pain. 93. tardive dyskinesia. it is important to maintain the hip in a state of abduction to prevent dislocation of the prosthesis. C. For each baby. 77. It is unnecessary check capillary refill. On the surgical side. No effective treatment is available for a mother with cytomegalovirus. 79. D. D. 75. 87. 65. After a total hip replacement. 80. A. 62. Administering a high volume of intravenous fluid and electrolytes to help compensate for the acidosis resulting from hypoxemia associated with sickle cell crisis is one way to accomplish this. 99. 82. D. Use of an abduction pillow or splint will not prevent the formation of sacral pressure ulcers. 88. 95. A. first dose of the DPT may be given at two months. Option B. C. the second is given around four months.61. C.neutral range of temperature' or 'Neutral Thermal Environment'. 86. B. A. B. 83. Delusion of reference is a false belief that public events or people are directly related to the individual. The patient is at risk for lymphedema and infection if blood pressures or venipuncture are done on the right arm. A. D. any ST-segment elevation. 81. Erythromycin ointment is not effective in treating neonatal chorioretinitis from cytomegalovirus. A. 64. Dentures are removed removed before the test. this range of temperature varies depending on gestational age. C. prolonged PR intervals. C. B. The medication may result in redness of the neonate’s eyes. A. and pseudoparkinsonism. Option B is expected during first trimester of pregnancy. new Q waves. 72. 98. The patient is taught to use the PCA as needed for pain control rather than at a set time. 91. C. oxygen utilization is least and baby thrives well is known as 'Thermo. and avoid crossing the leg beyond the midline of the body (e. new conduction defect. B. B. A. A. 92. The nurse allows the patient to examine the incision and participate in care when the patient feels ready. 89. The pregnant woman needs to be evaluated immediately for ectopic pregnancy. Extrapyramidal reactions include movement disorders such as dystonia. with a tracheal shift. A. B. for example. 90. not crossing the leg over the other leg). 85. D. should be instructed to decrease activity. Position of the trachea should be evaluated. The temperature range during which the basal metabolic rate of the baby is at a minimum.

C.A. D. 127. warm.A. The patient's statement recognizes that the activity is one that requires continued work. crush.A. including bowel and bladder.C.D.C. All visitors are restricted with regard to the distance they should be from the client. NSAIDs and warfarin. 129. The patient experiences a predominant parasympathetic stimulationthat causes vasodilation lasting for an extended period. 121. vomiting. Option C indicates resolution. and coarsening of hand tremors indicate lithium toxicity. vasodilation occurs as a result of a loss of balance between parasympathetic and sympathetic stimualtaion. thirst. due to dominance of the parasympathetic system (vagus nerve). bruit over site. A common side effect is diarrhea. 123. not Kaposi’s sarcoma. distance.B. Polio vaccine contains live virus and should not be given to children who are immunocompromised. lower back and abdominal pain. dry skin. 126.D. Hallmark of aseptic technique is handwashing. bloody stools.A. . Other options suggest exacerbation of the disease. not just for routine care. BP difference between extremities. but progress is being made toward the goal of developing as much independence as possible with eating. Take the drug with food or after meals if GI upset occurs. disappears after 3 to 4 months. It is manifested by hypotension. Fontanelle should feel soft and flat. hypothermia. 115. Appropriate shielding (lead aprons) is to be used when the nurse has to spend any length of time at a close distance.A. Diagnosis of rheumatic fever is based on the Jones criteria and positive laboratoty tests for: Increased erythrocyte sedimentation rate.B. 108.C. B. Patient is at risk for peritonitis. Unsteady gait. positive C-reactive protein. Option A is an Implementation.B. Patient has not lost civil right to use phone. E. pulsatile abdominal mass. nurse should decrease the time spent in close proximity to the client.D. gum bleeding (related to aspirin’s effects on blood clotting). don't remove exudate.D. Open Kaposi’s sarcoma lesions should be cleaned and dressed daily to prevent secondary infection. 119.A. fullness or bulging indicates increased intracranial pressure. easy bruising. 116. diarrhea. Do not cut. confusion. 118. complete assessment first. it is too soon for infection to occur secondary to surgery.B. motor reflex is normal. positive throat culture for group A beta haemolytic streptococci. due to vasodilation. positive antistreptolysin-O titer. By administering Librium. rapid or difficult breathing. Option A reveals small amount of bleeding and does not indicate acute bleeding. 100. bradycardia. 105. 120. dizziness. due to a reduction in systemic vascular resistance and venous return.C. Water should not be allowed to stand in containers. prolonged PR and QT intervals. Umbilical cord falls off within 1 to 2 weeks. during change of bag isa good time for stoma and skin to be closely inspected. nausea. Report ringing in the ears. flaccid paralysis. vomiting.113.B. Client should be encouraged to participate and should foster independence. revealed by ECG. F. The absence of spontaneous cough and presence of drooling and agitation are cardinal signs distinctive of epiglottitis.A.D. Client should use only the prescribed medications on the wound.A. and should be assessed for further symptoms of infection. 128. clean with warm water. Neurogenic shock is characterized by areflexia. 125. 104. shielding. A patient who is using modified feeding utensils at every meal is demonstrating an attempt at independence for the functional activity of eating. Warm tub bath is not done because of risk of secondary skin infection. 109. Option B suggests expected outcome.C. you will prevent delirium tremens that can possibly harm during the process.D. Option D is an inappropriate assessment. such as respiratory or suction equipment because this could act as a culture medium. Option B is an assessment but determine what is happening to the patient now. A goal when caring for patients with spinal cord injuries is to promote their adjustment to the injury and their independence. Patient is able to use phone unless otherwise indicated by court order or physician’s order. 106. slurred speech. 110. Signs and symptoms of abdominal aortic aneurysm include: diminished femoral pulses. no tub baths until the cord falls off. nausea. a lipid lowering-agent. In neurogenic shock. increase bleeding potential with aspirin. Normal healing of cirucmcision. peripheral ischemia. 117. 122. 114. or chew sustained-release products.A.A. It is important to keep the skin clean to prevent secondary skin infection but should be covered due to open areas. 112. Garlic.C. Assessment of the dressing should be checked on admission to the room and frequently for the next several hours. 107.D. abdominal pain. 101. 111. Diluted povidone-iodine is the treatment for herpes simplex virus abscess. 103. Principles for radiation therapy are time. 124. Nystatin is given for candida infections such as oral thrush. 102. Ostomy bags should be changed at least once a week or when seal arpunf stoma is loose or leaking.

E.B. Vitamin K food sources are green leafy vegetables. The dosage may need to be decreased because of side effect of medication. Hypertensive crisis. 143.C. dystonias (protrusion of tongue. 155. clammy skin.C.C. Applying lip balm or handling contact lenses is prohibited in work areas where exposure to bloodborne pathogens may occur. For epilepsy. private room with negative air pressure.C. 144. Option A demonstrates appropriate procedure. all staff members need to be included in program development.C. 156. Flushing. This is due to inflammatory response of the kidneys to incompatible blood. Failure to report abuse is a misdemeanor. 145.D. 151. Use the least restrictive interventions in ascending order. nausea. Use airborne precautions for TB. 142. Vascular collapse. 139. Tracheostomy set is the most important for the client's safety due to risk for laryngospasm.B. WBCs and RBCs should be present. 153. 161. Glucose increases during the inflammation process. is characterized by hypertension. 135.C.B. bradycardia. Assessment include Low back pain (first sign). vomiting. Hypotension. frontally radiating occipital headache. prevents airborne contamination. C.B. cauliflower and cabbage. and constricting chest pain may also be present. In HHNS. marketed in the US and most of Europe as Lamictal by GlaxoSmithKline. minimum of six exchanges per hour. Other options are reasonable recommendations to begin using in a systematic desensitization program after the crisis is alleviated.C. The patient may be experiencing hypocalcemia. To implement a behavior modification plan successfully.A. C. which could be the first signs of a hypertensive crisis. fever and chills. CNS dysfunction worsens as serum osmolarity rises. and time must be allowed for discussion of concerns from each nursing staff member.C. rigidity). sweating. 136. Blood should sit on the strip like a raindrop.D.D. Option A&B require contact precautions with no mask. A.C.D. Acute renal failure. 131. Droplet precautions used for organisms that can be transmitted by face-to-face contact. With the client’s complaints.E. Tachypnea. You should not cut extended-release tablets in half.C. Bleeding. 164. Morphine is an opioid narcotic analgesic that can depress respiration.B 149. consistency and follow-through is important to prevent or diminish the level of manipulation by the staff or client during implementation of this program. 134. door may remain open. abnormal posturing).A.B. 141. The nurse must immediately call and report the suspected abuse.A. 140. Postural hypotension can be a result of dizziness owing to the use of low-potency antipsychotics such as chlorpromazine or thioridazine. 133. Candy or another simple sugar is carried and used to treat mild hypoglycemia episodes. both adverse and therapeutic.130. 1 milligram = 1000 mcg 160.B. 159. 162. and coma are caused by intracellular dehydration and hyperosmolarity. seizures. and dyskinesia (stiff neck. it is not a primary component in determining urinary tract infections. and palpitations.C. . Option C requires standard precautions. The client is taught to be alert to any occipital headache radiating frontally and neck stiffness or soreness.B. 152.D. 150. pseudoparkinsonism (tremors. Thorazine is an antipsychotic medication. CNS depression. Support groups of people who have suffered similar acts of violence can be helpful and supportive to teach clients how to deal with the traumatizing situation and the emotional aftermath. difficulty swallowing). 137. is an anticonvulsant drug used in the treatment of epilepsy and bipolar disorder. D. 163. an adverse effect of this medication.A. of opioid narcotic analgesics.B. Insulin is the only medication that can be given. Urinary output of less than 30ml/hr should reported to the physician. smearing alters the reading. disorientation or mental confusion. It is also used off-label as an adjunct in treating depression. Acute phase of burn injury occurs from beginning of diuresis to the near completion of wound closure Characterized by fluid shift from interstitial to intravascular. Hypertensive crisis is treated with (Nifedipine) Procardia. Hemolytic Reaction is a type of complication of blood transfusion is caused by infusion of incompatible blood products. it is used to treat focal seizures. 148.D. Narcotics are most often used intravenously 165. 138. 146. RBCs are increased when bladder mucosa is irritated and bleeding. Extrapyramidal side effects resulting from this medication include akathisia (motor restlessness).A. WBCs are a response to the inflammation process and irritation of the urethra. 132. Option B is not accurat. primary and secondary tonic-clonic seizures. Anhedonia—the loss of interest and pleasure in activities—is a sign of depression. 154.D.C. Milking forces interstitial fluid to mix with capillary blood and dilutes the blood. Naloxone is a narcotic antagonist that can reverse the effects.A. 147. 157. 166. Dangling helps facilitates venous congestion. Sticking on the side is less painful that the center of the fingertip. neck stiffness and soreness. antiparkinsonian drug such as Cogentin may be ordered. Lamotrigine. and seizures associated with Lennox-Gastautsyndrome. dilated pupils. Tachycardia.C. Chills. 158. compatible with TPN. Alteplase is a tissue plasminogen activator which induce fibrinolysis that causes bleeding.D.D. Feeling of fullness. Tachycardia.

not by auscultation. Vit B6/Pyridoxine is given.C.A.G.B.B. The mainstay of drug therapy for PEA is epinephrine 1 mg every 3–5 minutes." and by taking the specimen quickly. 188. 179. 175. Confirm the presence of lice before excluding from duty. 178. During CPR.D. 198. 194. Assessment should be done first. 189. Diabetic retinopathy leads to development of microaneurysms and intraretinal haemorrhage. Using sterile gloves to remove the dressing would contaminate them.C. 168. Isotonic solutios are not best with dehydration. The nurse is not obligated to report information that is not relevant to the client’s care or well-being. 185.) Electromyography (EMG) assesses electrical activity associated with nerves and skeletal muscles. cooking fat applied to an open wound increases the possibility of infection. Lactated Ringer’s is an isotonic solution used to replace electrolytes. may be carried out after the patency of the tube is determined. . they are more susceptible to infections. 197. if lice present.B. Polypharmacy means that multiple medications have been prescribed. active in some clients. may be decreased by having the client sit upright if health permits. usually in the lower abdominal area. To obtain a throat culture specimen.C. especially irrigating a wound. Because leukemic clients are immunosuppressed. Should first assess if the tube is open and draining to determine if there is a problem with the nasogastric tube.D. There is no risk of electric shock with this procedure. 196.B. the carotid artery pulse is the most accessible and may persist when the peripheral pulses (radial and brachial) no longer are palpable because of decreases in cardiac output and peripheral perfusion. 181. 195.C. Hypertonic solutions are contraindicated in dehydration.D.D. exclude from patient care until appropriate treatment has been received and shown to be effective. Anticipatory grief is associated with the anticipation of a death or loss that has yet to take place. The statement "You've been upset about your blood pressure" is a reflective comment that describes the patient's feelings.B.A. You should inform the patient that pain and discomfort are associated with insertion of needles.C. Apply Kwell shampoo to dry hair and work into lather for 4–5 minutes 192. 184. A reflective comment repeats what a patient has said or describes the person's feelings. Magnesium Sulfate is used to reduce preterm labor contractions and prevent seizures in PreEclampsia 169.B. 170.C.D. then inserts the swab into the oropharynx and runs the swab along the tonsils and areas on the pharynx that are reddened or contain exudate. treat with gamma-benzene hexachloride (Kwell). 177. 173. 182. 190. Needle electrodes are inserted to detect muscle and peripheral nerve disease.A. 201. 176. The gag reflex.C. if it is patent and draining it does not need to be irrigated. 171. anticipatory. Isoniazid/INH can causes peripheral neuritis. 186.C. and does not address 199.A. A patient who is newly diagnosed with liver cancer is most likely to experience anticipatory grieving when anticipating death. extend the tongue. The nurse must never agree to keep information confidential without knowing the content of the information. burns should be rinsed immediately with tap water to reduce the heat in the burn.D.B.D. 183. 174. Hypotonic solution.D. Dalteparin is given by subcutaneous (under the skin) injection.C. The nurse is obligated to share client information with personnel directly involved with the client’s care. Grief can be classified as acute. the nurse puts on clean gloves. and say "ah. open the mouth.C. or pathologic. Handwashing should be done prior to beginning any procedure. Reporting the physician is unnecessary unless signs of wound infection is noted.A. shifts fluid into intracellular space to correct dehydration. 172. 193. Documentation is done later. It is used by the nurse to encourage the patient to elaborate on the topic. Patency should be checked first by aspirating stomach contents.C. People who have an allergy to shellfish or iodine may experience an allergic reaction to the contrast dye. 191. Option A & B.A.E.C. 180. Observe for movement (louse) or small whitish oval specks that adhere to the hair shaft (nits). 200. the immediate problem of cleansing the wound.D.F. (B.167.C. Indicates cardiovascular fluid overload. 187.D.