1. Nurse Betty is assigned to the following clients.

The client that the nurse would see first

after endorsement?

a. A 34 year-old post operative appendectomy client of five hours who is complaining of

pain.
b. A 44 year-old myocardial infarction (MI) client who is complaining of nausea.
c. A 26 year-old client admitted for dehydration whose intravenous (IV) has infiltrated.
d. A 63 year-old post operative’s abdominal hysterectomy client of three days whose
incisional dressing is saturated with serosanguinous fluid.

2. Nurse Gail places a client in a four-point restraint following orders from the physician.
The client care plan should include:

a. Assess temperature frequently.

b. Provide diversional activities.
c. Check circulation every 15-30 minutes.
d. Socialize with other patients once a shift.

3. A male client who has severe burns is receiving H2 receptor antagonist therapy. The
nurse In-charge knows the purpose of this therapy is to:

a. Prevent stress ulcer

b. Block prostaglandin synthesis
c. Facilitate protein synthesis.
d. Enhance gas exchange

4. The doctor orders hourly urine output measurement for a postoperative male client. The
nurse Trish records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml;
9 a.m.: 60 ml. Based on these amounts, which action should the nurse take?

a. Increase the I.V. fluid infusion rate

b. Irrigate the indwelling urinary catheter
c. Notify the physician
d. Continue to monitor and record hourly urine output

5. Tony, a basketball player twist his right ankle while playing on the court and seeks care
for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which
statement by Tony suggests that ice application has been effective?

a. “My ankle looks less swollen now”.

b. “My ankle feels warm”.
c. “My ankle appears redder now”.
d. “I need something stronger for pain relief”

6.The physician prescribes a loop diuretic for a client. When administering this drug, the
nurse anticipates that the client may develop which electrolyte imbalance?

a. Hypernatremia
b. Hyperkalemia
c. Hypokalemia
d. Hypervolemia

7.She finds out that some managers have benevolent-authoritative style of management.
Which of the following behaviors will she exhibit most likely?

a. Have condescending trust and confidence in their subordinates.

b. Gives economic and ego awards.
c. Communicates downward to staffs.
d. Allows decision making among subordinates.

8. Nurse Amy is aware that the following is true about functional nursing

a. Provides continuous, coordinated and comprehensive nursing services.

b. One-to-one nurse patient ratio.
c. Emphasize the use of group collaboration.
d. Concentrates on tasks and activities.

9.Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3 days?"

a. Single order
b. Standard written order
c. Standing order
d. Stat order

10.A female client with a fecal impaction frequently exhibits which clinical manifestation?

a. Increased appetite
b. Loss of urge to defecate
c. Hard, brown, formed stools
d. Liquid or semi-liquid stools

11.Nurse Linda prepares to perform an otoscopic examination on a female client. For proper
visualization, the nurse should position the client's ear by:

a. Pulling the lobule down and back

b. Pulling the helix up and forward
c. Pulling the helix up and back
d. Pulling the lobule down and forward

12. Nurse Michelle is assessing a 24 year old client with a diagnosis of hydatidiform mole.
She is aware that one of the following is unassociated with this condition?
a. Excessive fetal activity.
b. Larger than normal uterus for gestational age.
c. Vaginal bleeding
d. Elevated levels of human chorionic gonadotropin.

13. A pregnant client is receiving magnesium sulfate for severe pregnancy induced
hypertension (PIH). The clinical findings that would warrant use of the antidote , calcium
gluconate is:

a. Urinary output 90 cc in 2 hours.

b. Absent patellar reflexes.
c. Rapid respiratory rate above 40/min.
d. Rapid rise in blood pressure.

14. During vaginal examination of Janah who is in labor, the presenting part is at station
plus two. Nurse, correctly interprets it as:

a. Presenting part is 2 cm above the plane of the ischial spines.

b. Biparietal diameter is at the level of the ischial spines.
c. Presenting part in 2 cm below the plane of the ischial spines.
d. Biparietal diameter is 2 cm above the ischial spines.

15. A pregnant client is receiving oxytocin (Pitocin) for induction of labor. A condition that
warrant the nurse in-charge to discontinue I.V. infusion of Pitocin is:

a. Contractions every 1 ½ minutes lasting 70-80 seconds.

b. Maternal temperature 101.2
c. Early decelerations in the fetal heart rate.
d. Fetal heart rate baseline 140-160 bpm.

16. Calcium gluconate is being administered to a client with pregnancy induced

hypertension (PIH). A nursing action that must be initiated as the plan of care throughout
injection of the drug is:

a. Ventilator assistance
b. CVP readings
c. EKG tracings
d. Continuous CPR

17. A trial for vaginal delivery after an earlier caesareans, would likely to be given to a
gravida, who had:

a. First low transverse cesarean was for active herpes type 2 infections; vaginal culture at
39 weeks pregnancy was positive.
b. First and second caesareans were for cephalopelvic disproportion.
c. First caesarean through a classic incision as a result of severe fetal distress.
d. First low transverse caesarean was for breech position. Fetus in this pregnancy is in a
vertex presentation.

18.Nurse Ryan is aware that the best initial approach when trying to take a crying toddler’s
temperature is:

a. Talk to the mother first and then to the toddler.

b. Bring extra help so it can be done quickly.
c. Encourage the mother to hold the child.
d. Ignore the crying and screaming.

19.Baby Tina a 3 month old infant just had a cleft lip and palate repair. What should the
nurse do to prevent trauma to operative site?

a. Avoid touching the suture line, even when cleaning.

b. Place the baby in prone position.
c. Give the baby a pacifier.
d. Place the infant’s arms in soft elbow restraints.

20. Which action should nurse Marian include in the care plan for a 2 month old with heart
failure?

a. Feed the infant when he cries.

b. Allow the infant to rest before feeding.
c. Bathe the infant and administer medications before feeding.
d. Weigh and bathe the infant before feeding.

21.Nurse Hazel is teaching a mother who plans to discontinue breast feeding after 5
months. The nurse should advise her to include which foods in her infant’s diet?

a. Skim milk and baby food.

b. Whole milk and baby food.
c. Iron-rich formula only.
d. Iron-rich formula and baby food.

22. Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on
the side rails of the bed and unresponsive to shaking or shouting. Which is the nurse next
action?

a. Call for help and note the time.

b. Clear the airway
c. Give two sharp thumps to the precordium, and check the pulse.
d. Administer two quick blows.

23. Nurse Monett is caring for a client recovering from gastro-intestinal bleeding. The nurse
should:

a. Plan care so the client can receive 8 hours of uninterrupted sleep each night.
b. Monitor vital signs every 2 hours.
c. Make sure that the client takes food and medications at prescribed intervals.
d. Provide milk every 2 to 3 hours.

24. A male client was on warfarin (Coumadin) before admission, and has been receiving
heparin I.V. for 2 days. The partial thromboplastin time (PTT) is 68 seconds. What should
Nurse Carla do?

a. Stop the I.V. infusion of heparin and notify the physician.

b. Continue treatment as ordered.
c. Expect the warfarin to increase the PTT.
d. Increase the dosage, because the level is lower than normal.

25. A client undergone ileostomy, when should the drainage appliance be applied to the
stoma?

a. 24 hours later, when edema has subsided.

b. In the operating room.
c. After the ileostomy begin to function.
d. When the client is able to begin self-care procedures.

26. A client undergone spinal anesthetic, it will be important that the nurse immediately
position the client in:

a. On the side, to prevent obstruction of airway by tongue.

b. Flat on back.
c. On the back, with knees flexed 15 degrees.
d. Flat on the stomach, with the head turned to the side.

27.While monitoring a male client several hours after a motor vehicle accident, which
assessment data suggest increasing intracranial pressure?

a. Blood pressure is decreased from 160/90 to 110/70.

b. Pulse is increased from 87 to 95, with an occasional skipped beat.
c. The client is oriented when aroused from sleep, and goes back to sleep immediately.
d. The client refuses dinner because of anorexia.

28.Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms
may appear first?

a. Altered mental status and dehydration

b. Fever and chills
c. Hemoptysis and Dyspnea
d. Pleuritic chest pain and cough

29. A male client has active tuberculosis (TB). Which of the following symptoms will be
exhibit?
a. Chest and lower back pain
b. Chills, fever, night sweats, and hemoptysis
c. Fever of more than 104°F (40°C) and nausea
d. Headache and photophobia

30. Mark, a 7-year-old client is brought to the emergency department. He’s tachypneic and
afebrile and has a respiratory rate of 36 breaths/minute and has
a nonproductive cough. He recently had a cold. Form this history; the client may have which
of the following conditions?

a. Acute asthma
b. Bronchial pneumonia
c. Chronic obstructive pulmonary disease (COPD)
d. Emphysema

31. Marichu was given morphine sulfate for pain. She is sleeping and her respiratory rate is
4 breaths/minute. If action isn’t taken quickly, she might have
which of the following reactions?

a. Asthma attack
b. Respiratory arrest
c. Seizure
d. Wake up on his own

32. A 77-year-old male client is admitted for elective knee surgery. Physical examination
reveals shallow respirations but no sign of respiratory distress. Which of the following is a
normal physiologic change related to aging?

a. Increased elastic recoil of the lungs

b. Increased number of functional capillaries in the alveoli
c. Decreased residual volume
d. Decreased vital capacity

33. Tracy is receiving combination chemotherapy for treatment of metastatic carcinoma.

Nurse Ruby should monitor the client for the systemic side effect of:

a. Ascites
b. Nystagmus
c. Leukopenia
d. Polycythemia

34. Norma, with recent colostomy expresses concern about the inability to control the
passage of gas. Nurse Oliver should suggest that the client plan to:

a. Eliminate foods high in cellulose.

b. Decrease fluid intake at meal times.
c. Avoid foods that in the past caused flatus.
d. Adhere to a bland diet prior to social events.

35. Nurse Ron begins to teach a male client how to perform colostomy irrigations. The nurse
would evaluate that the instructions were understood when the client states, “I should:

a. Lie on my left side while instilling the irrigating solution.”

b. Keep the irrigating container less than 18 inches above the stoma.”
c. Instill a minimum of 1200 ml of irrigating solution to stimulate
evacuation of the bowel.”
d. Insert the irrigating catheter deeper into the stoma if cramping
occurs during the procedure.”

36. Patrick is in the oliguric phase of acute tubular necrosis and is experiencing fluid and
electrolyte imbalances. The client is somewhat confused and complains of nausea and
muscle weakness. As part of the prescribed therapy to correct this electrolyte imbalance,
the nurse would expect to:

a. Administer Kayexalate
b. Restrict foods high in protein
c. Increase oral intake of cheese and milk.
d. Administer large amounts of normal saline via I.V.

37. Mario has burn injury. After Forty48 hours, the physician orders for Mario 2 liters of IV
fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should
set the flow to provide:

a. 18 gtt/min
b. 28 gtt/min
c. 32 gtt/min
d. 36 gtt/min

38.Terence suffered form burn injury. Using the rule of nines, which has the largest percent
of burns?

a. Face and neck

b. Right upper arm and penis
c. Right thigh and penis
d. Upper trunk

39. Herbert, a 45 year old construction engineer is brought to the hospital unconscious after
falling from a 2-story building. When assessing the client, the nurse would be most
concerned if the assessment revealed:

a. Reactive pupils
b. A depressed fontanel
c. Bleeding from ears
d. An elevated temperature
40. Nurse Sherry is teaching male client regarding his permanent artificial pacemaker.
Which information given by the nurse shows her knowledge deficit about the artificial
cardiac pacemaker?

a. take the pulse rate once a day, in the morning upon awakening
b. May be allowed to use electrical appliances
c. Have regular follow up care
d. May engage in contact sports

41.The nurse is ware that the most relevant knowledge about oxygen administration to a
male client with COPD is

a. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.

b. Hypoxia stimulates the central chemoreceptors in the medulla that makes the client
breath.
c. Oxygen is administered best using a non-rebreathing mask
d. Blood gases are monitored using a pulse oximeter.

42.Tonny has undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are
inserted, and one-bottle water-seal drainage is instituted in the operating room. In the
postanesthesia care unit Tonny is placed in Fowler's position on either his right side or on
his back. The nurse is aware that this position:

a. Reduce incisional pain.

b. Facilitate ventilation of the left lung.
c. Equalize pressure in the pleural space.
d. Increase venous return

43. What is Nurse John likely to note in a male client being admitted for alcohol withdrawal?

a. Perceptual disorders.
b. Impending coma.
c. Recent alcohol intake.
d. Depression with mutism.

44. Aira has taken amitriptyline HCL (Elavil) for 3 days, but now complains that it “doesn’t
help” and refuses to take it. What should the nurse say or do?

a. Withhold the drug.

b. Record the client’s response.
c. Encourage the client to tell the doctor.
d. Suggest that it takes awhile before seeing the results.

45. Dervid, an adolescent has a history of truancy from school, running away from home
and “barrowing” other people’s things without their permission. The adolescent denies
stealing, rationalizing instead that as long as no one was using the items, it was all right to
borrow them. It is important for the nurse to understand the psychodynamically, this
behavior may be largely attributed to a developmental defect related to the:

a. Id
b. Ego
c. Superego
d. Oedipal complex

46. In preparing a female client for electroconvulsive therapy (ECT), Nurse Michelle knows
that succinylcoline (Anectine) will be administered for which therapeutic effect?

a. Short-acting anesthesia
b. Decreased oral and respiratory secretions.
c. Skeletal muscle paralysis.
d. Analgesia.

47. Nurse Gina is aware that the dietary implications for a client in manic phase of bipolar
disorder is:

a. Serve the client a bowl of soup, buttered French bread, and apple slices.
b. Increase calories, decrease fat, and decrease protein.
c. Give the client pieces of cut-up steak, carrots, and an apple.
d. Increase calories, carbohydrates, and protein.

48.What parental behavior toward a child during an admission procedure should cause
Nurse Ron to suspect child abuse?

a. Flat affect
b. Expressing guilt
c. Acting overly solicitous toward the child.
d. Ignoring the child.

49.Nurse Lynnette notices that a female client with obsessive-compulsive disorder washes
her hands for long periods each day. How should the nurse respond to this compulsive
behavior?

a. By designating times during which the client can focus on the behavior.
b. By urging the client to reduce the frequency of the behavior as rapidly as possible.
c. By calling attention to or attempting to prevent the behavior.
d. By discouraging the client from verbalizing anxieties.

50.After seeking help at an outpatient mental health clinic, Ruby who was raped while
walking her dog is diagnosed with posttraumatic stress disorder (PTSD). Three months
later, Ruby returns to the clinic, complaining of fear, loss of control, and helpless feelings.
Which nursing intervention is most appropriate for Ruby?

a. Recommending a high-protein, low-fat diet.

b. Giving sleep medication, as prescribed, to restore a normal sleepwake cycle.
c. Allowing the client time to heal.
d. Exploring the meaning of the traumatic event with the client.

1. Nurse Betty is assigned to the following clients. The client that the nurse would see first
after endorsement?

a. A 34 year-old post operative appendectomy client of five hours who is complaining of

pain.
b. A 44 year-old myocardial infarction (MI) client who is complaining of nausea.
c. A 26 year-old client admitted for dehydration whose intravenous (IV) has infiltrated.
d. A 63 year-old post operative’s abdominal hysterectomy client of three days whose
incisional dressing is saturated with serosanguinous fluid.

2. Nurse Gail places a client in a four-point restraint following orders from the physician.
The client care plan should include:

a. Assess temperature frequently.

b. Provide diversional activities.
c. Check circulation every 15-30 minutes.
d. Socialize with other patients once a shift.

3. A male client who has severe burns is receiving H2 receptor antagonist therapy. The
nurse In-charge knows the purpose of this therapy is to:

a. Prevent stress ulcer

b. Block prostaglandin synthesis
c. Facilitate protein synthesis.
d. Enhance gas exchange

4. The doctor orders hourly urine output measurement for a postoperative male client. The
nurse Trish records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml;
9 a.m.: 60 ml. Based on these amounts, which action should the nurse take?

a. Increase the I.V. fluid infusion rate

b. Irrigate the indwelling urinary catheter
c. Notify the physician
d. Continue to monitor and record hourly urine output

5. Tony, a basketball player twist his right ankle while playing on the court and seeks care
for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which
statement by Tony suggests that ice application has been effective?

a. “My ankle looks less swollen now”.

b. “My ankle feels warm”.
c. “My ankle appears redder now”.
d. “I need something stronger for pain relief”
6.The physician prescribes a loop diuretic for a client. When administering this drug, the
nurse anticipates that the client may develop which electrolyte imbalance?

a. Hypernatremia
b. Hyperkalemia
c. Hypokalemia
d. Hypervolemia

7.She finds out that some managers have benevolent-authoritative style of management.
Which of the following behaviors will she exhibit most likely?

a. Have condescending trust and confidence in their subordinates.

b. Gives economic and ego awards.
c. Communicates downward to staffs.
d. Allows decision making among subordinates.

8. Nurse Amy is aware that the following is true about functional nursing

a. Provides continuous, coordinated and comprehensive nursing services.

b. One-to-one nurse patient ratio.
c. Emphasize the use of group collaboration.
d. Concentrates on tasks and activities.

9.Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3 days?"

a. Single order
b. Standard written order
c. Standing order
d. Stat order

10.A female client with a fecal impaction frequently exhibits which clinical manifestation?

a. Increased appetite
b. Loss of urge to defecate
c. Hard, brown, formed stools
d. Liquid or semi-liquid stools

11.Nurse Linda prepares to perform an otoscopic examination on a female client. For proper
visualization, the nurse should position the client's ear by:

a. Pulling the lobule down and back

b. Pulling the helix up and forward
c. Pulling the helix up and back
d. Pulling the lobule down and forward
12. Nurse Michelle is assessing a 24 year old client with a diagnosis of hydatidiform mole.
She is aware that one of the following is unassociated with this condition?

a. Excessive fetal activity.

b. Larger than normal uterus for gestational age.
c. Vaginal bleeding
d. Elevated levels of human chorionic gonadotropin.

13. A pregnant client is receiving magnesium sulfate for severe pregnancy induced
hypertension (PIH). The clinical findings that would warrant use of the antidote , calcium
gluconate is:

a. Urinary output 90 cc in 2 hours.

b. Absent patellar reflexes.
c. Rapid respiratory rate above 40/min.
d. Rapid rise in blood pressure.

14. During vaginal examination of Janah who is in labor, the presenting part is at station
plus two. Nurse, correctly interprets it as:

a. Presenting part is 2 cm above the plane of the ischial spines.

b. Biparietal diameter is at the level of the ischial spines.
c. Presenting part in 2 cm below the plane of the ischial spines.
d. Biparietal diameter is 2 cm above the ischial spines.

15. A pregnant client is receiving oxytocin (Pitocin) for induction of labor. A condition that
warrant the nurse in-charge to discontinue I.V. infusion of Pitocin is:

a. Contractions every 1 ½ minutes lasting 70-80 seconds.

b. Maternal temperature 101.2
c. Early decelerations in the fetal heart rate.
d. Fetal heart rate baseline 140-160 bpm.

16. Calcium gluconate is being administered to a client with pregnancy induced

hypertension (PIH). A nursing action that must be initiated as the plan of care throughout
injection of the drug is:

a. Ventilator assistance
b. CVP readings
c. EKG tracings
d. Continuous CPR

17. A trial for vaginal delivery after an earlier caesareans, would likely to be given to a
gravida, who had:

a. First low transverse cesarean was for active herpes type 2 infections; vaginal culture at
39 weeks pregnancy was positive.
b. First and second caesareans were for cephalopelvic disproportion.
c. First caesarean through a classic incision as a result of severe fetal distress.
d. First low transverse caesarean was for breech position. Fetus in this pregnancy is in a
vertex presentation.

18.Nurse Ryan is aware that the best initial approach when trying to take a crying toddler’s
temperature is:

a. Talk to the mother first and then to the toddler.

b. Bring extra help so it can be done quickly.
c. Encourage the mother to hold the child.
d. Ignore the crying and screaming.

19.Baby Tina a 3 month old infant just had a cleft lip and palate repair. What should the
nurse do to prevent trauma to operative site?

a. Avoid touching the suture line, even when cleaning.

b. Place the baby in prone position.
c. Give the baby a pacifier.
d. Place the infant’s arms in soft elbow restraints.

20. Which action should nurse Marian include in the care plan for a 2 month old with heart
failure?

a. Feed the infant when he cries.

b. Allow the infant to rest before feeding.
c. Bathe the infant and administer medications before feeding.
d. Weigh and bathe the infant before feeding.

21.Nurse Hazel is teaching a mother who plans to discontinue breast feeding after 5
months. The nurse should advise her to include which foods in her infant’s diet?

a. Skim milk and baby food.

b. Whole milk and baby food.
c. Iron-rich formula only.
d. Iron-rich formula and baby food.

22. Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on
the side rails of the bed and unresponsive to shaking or shouting. Which is the nurse next
action?

a. Call for help and note the time.

b. Clear the airway
c. Give two sharp thumps to the precordium, and check the pulse.
d. Administer two quick blows.

23. Nurse Monett is caring for a client recovering from gastro-intestinal bleeding. The nurse
should:
a. Plan care so the client can receive 8 hours of uninterrupted sleep each night.
b. Monitor vital signs every 2 hours.
c. Make sure that the client takes food and medications at prescribed intervals.
d. Provide milk every 2 to 3 hours.

24. A male client was on warfarin (Coumadin) before admission, and has been receiving
heparin I.V. for 2 days. The partial thromboplastin time (PTT) is 68 seconds. What should
Nurse Carla do?

a. Stop the I.V. infusion of heparin and notify the physician.

b. Continue treatment as ordered.
c. Expect the warfarin to increase the PTT.
d. Increase the dosage, because the level is lower than normal.

25. A client undergone ileostomy, when should the drainage appliance be applied to the
stoma?

a. 24 hours later, when edema has subsided.

b. In the operating room.
c. After the ileostomy begin to function.
d. When the client is able to begin self-care procedures.

26. A client undergone spinal anesthetic, it will be important that the nurse immediately
position the client in:

a. On the side, to prevent obstruction of airway by tongue.

b. Flat on back.
c. On the back, with knees flexed 15 degrees.
d. Flat on the stomach, with the head turned to the side.

27.While monitoring a male client several hours after a motor vehicle accident, which
assessment data suggest increasing intracranial pressure?

a. Blood pressure is decreased from 160/90 to 110/70.

b. Pulse is increased from 87 to 95, with an occasional skipped beat.
c. The client is oriented when aroused from sleep, and goes back to sleep immediately.
d. The client refuses dinner because of anorexia.

28.Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms
may appear first?

a. Altered mental status and dehydration

b. Fever and chills
c. Hemoptysis and Dyspnea
d. Pleuritic chest pain and cough
29. A male client has active tuberculosis (TB). Which of the following symptoms will be
exhibit?

a. Chest and lower back pain

b. Chills, fever, night sweats, and hemoptysis
c. Fever of more than 104°F (40°C) and nausea
d. Headache and photophobia

30. Mark, a 7-year-old client is brought to the emergency department. He’s tachypneic and
afebrile and has a respiratory rate of 36 breaths/minute and has
a nonproductive cough. He recently had a cold. Form this history; the client may have which
of the following conditions?

a. Acute asthma
b. Bronchial pneumonia
c. Chronic obstructive pulmonary disease (COPD)
d. Emphysema

31. Marichu was given morphine sulfate for pain. She is sleeping and her respiratory rate is
4 breaths/minute. If action isn’t taken quickly, she might have
which of the following reactions?

a. Asthma attack
b. Respiratory arrest
c. Seizure
d. Wake up on his own

32. A 77-year-old male client is admitted for elective knee surgery. Physical examination
reveals shallow respirations but no sign of respiratory distress. Which of the following is a
normal physiologic change related to aging?

a. Increased elastic recoil of the lungs

b. Increased number of functional capillaries in the alveoli
c. Decreased residual volume
d. Decreased vital capacity

33. Tracy is receiving combination chemotherapy for treatment of metastatic carcinoma.

Nurse Ruby should monitor the client for the systemic side effect of:

a. Ascites
b. Nystagmus
c. Leukopenia
d. Polycythemia

34. Norma, with recent colostomy expresses concern about the inability to control the
passage of gas. Nurse Oliver should suggest that the client plan to:

a. Eliminate foods high in cellulose.

b. Decrease fluid intake at meal times.
c. Avoid foods that in the past caused flatus.
d. Adhere to a bland diet prior to social events.

35. Nurse Ron begins to teach a male client how to perform colostomy irrigations. The nurse
would evaluate that the instructions were understood when the client states, “I should:

a. Lie on my left side while instilling the irrigating solution.”

b. Keep the irrigating container less than 18 inches above the stoma.”
c. Instill a minimum of 1200 ml of irrigating solution to stimulate
evacuation of the bowel.”
d. Insert the irrigating catheter deeper into the stoma if cramping
occurs during the procedure.”

36. Patrick is in the oliguric phase of acute tubular necrosis and is experiencing fluid and
electrolyte imbalances. The client is somewhat confused and complains of nausea and
muscle weakness. As part of the prescribed therapy to correct this electrolyte imbalance,
the nurse would expect to:

a. Administer Kayexalate
b. Restrict foods high in protein
c. Increase oral intake of cheese and milk.
d. Administer large amounts of normal saline via I.V.

37. Mario has burn injury. After Forty48 hours, the physician orders for Mario 2 liters of IV
fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should
set the flow to provide:

a. 18 gtt/min
b. 28 gtt/min
c. 32 gtt/min
d. 36 gtt/min

38.Terence suffered form burn injury. Using the rule of nines, which has the largest percent
of burns?

a. Face and neck

b. Right upper arm and penis
c. Right thigh and penis
d. Upper trunk

39. Herbert, a 45 year old construction engineer is brought to the hospital unconscious after
falling from a 2-story building. When assessing the client, the nurse would be most
concerned if the assessment revealed:

a. Reactive pupils
b. A depressed fontanel
c. Bleeding from ears
d. An elevated temperature

40. Nurse Sherry is teaching male client regarding his permanent artificial pacemaker.
Which information given by the nurse shows her knowledge deficit about the artificial
cardiac pacemaker?

a. take the pulse rate once a day, in the morning upon awakening
b. May be allowed to use electrical appliances
c. Have regular follow up care
d. May engage in contact sports

41.The nurse is ware that the most relevant knowledge about oxygen administration to a
male client with COPD is

a. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.

b. Hypoxia stimulates the central chemoreceptors in the medulla that makes the client
breath.
c. Oxygen is administered best using a non-rebreathing mask
d. Blood gases are monitored using a pulse oximeter.

42.Tonny has undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are
inserted, and one-bottle water-seal drainage is instituted in the operating room. In the
postanesthesia care unit Tonny is placed in Fowler's position on either his right side or on
his back. The nurse is aware that this position:

a. Reduce incisional pain.

b. Facilitate ventilation of the left lung.
c. Equalize pressure in the pleural space.
d. Increase venous return

43. What is Nurse John likely to note in a male client being admitted for alcohol withdrawal?

a. Perceptual disorders.
b. Impending coma.
c. Recent alcohol intake.
d. Depression with mutism.

44. Aira has taken amitriptyline HCL (Elavil) for 3 days, but now complains that it “doesn’t
help” and refuses to take it. What should the nurse say or do?

a. Withhold the drug.

b. Record the client’s response.
c. Encourage the client to tell the doctor.
d. Suggest that it takes awhile before seeing the results.

45. Dervid, an adolescent has a history of truancy from school, running away from home
and “barrowing” other people’s things without their permission. The adolescent denies
stealing, rationalizing instead that as long as no one was using the items, it was all right to
borrow them. It is important for the nurse to understand the psychodynamically, this
behavior may be largely attributed to a developmental defect related to the:

a. Id
b. Ego
c. Superego
d. Oedipal complex

46. In preparing a female client for electroconvulsive therapy (ECT), Nurse Michelle knows
that succinylcoline (Anectine) will be administered for which therapeutic effect?

a. Short-acting anesthesia
b. Decreased oral and respiratory secretions.
c. Skeletal muscle paralysis.
d. Analgesia.

47. Nurse Gina is aware that the dietary implications for a client in manic phase of bipolar
disorder is:

a. Serve the client a bowl of soup, buttered French bread, and apple slices.
b. Increase calories, decrease fat, and decrease protein.
c. Give the client pieces of cut-up steak, carrots, and an apple.
d. Increase calories, carbohydrates, and protein.

48.What parental behavior toward a child during an admission procedure should cause
Nurse Ron to suspect child abuse?

a. Flat affect
b. Expressing guilt
c. Acting overly solicitous toward the child.
d. Ignoring the child.

49.Nurse Lynnette notices that a female client with obsessive-compulsive disorder washes
her hands for long periods each day. How should the nurse respond to this compulsive
behavior?

a. By designating times during which the client can focus on the behavior.
b. By urging the client to reduce the frequency of the behavior as rapidly as possible.
c. By calling attention to or attempting to prevent the behavior.
d. By discouraging the client from verbalizing anxieties.

50.After seeking help at an outpatient mental health clinic, Ruby who was raped while
walking her dog is diagnosed with posttraumatic stress disorder (PTSD). Three months
later, Ruby returns to the clinic, complaining of fear, loss of control, and helpless feelings.
Which nursing intervention is most appropriate for Ruby?
a. Recommending a high-protein, low-fat diet.
b. Giving sleep medication, as prescribed, to restore a normal sleepwake cycle.
c. Allowing the client time to heal.
d. Exploring the meaning of the traumatic event with the client.