MS TEST-QUESTIONAIRE 2

1. After a cerebrovascular accident, a 75 yr old client is admitted to the health care facility. The client has
left-sided weakness and an absent gag reflex. He’s incontinent and has a tarry stool. His blood pressure is
90/50 mm Hg, and his hemoglobin is 10 g/dl. Which of the following is a priority for this client?

A.checking stools for occult blood

B.performing range-of-motion exercises to the left side

C.keeping skin clean and dry

D.elevating the head of the bed to 30 degrees

2. The nurse is caring for a client with a colostomy. The client tells the nurse that he makes small pin
holes in the drainage bag to help relieve gas. The nurse should teach him that this action:

A.destroys the odor-proof seal

B.wont affect the colostomy system

C.is appropriate for relieving the gas in a colostomy system

D.destroys the moisture barrier seal

3. When assessing the client with celiac disease, the nurse can expect to find which of the following?

A.steatorrhea

B.jaundiced sclerae

C.clay-colored stools

D.widened pulse pressure

4. A client is hospitalized with a diagnosis of chronic glomerulonephritis. The client mentions that she
likes salty foods. The nurse should warn her to avoid foods containing sodium because:

A.reducing sodium promotes urea nitrogen excretion

B.reducing sodium improves her glomerular filtration rate

C.reducing sodium increases potassium absorption

D.reducing sodium decreases edema

5. The nurse is caring for a client with a cerebral injury that impaired his speech and hearing. Most likely,
the client has experienced damage to the:
A.frontal lobe

B.parietal lobe

C.occipital lobe

D.temporal lobe

6. The nurse is assessing a postcraniotomy client and finds the urine output from a catheter is 1500 ml
for the 1st hour and the same for the 2nd hour. The nurse should suspect:

A.Cushing’s syndrome

B.Diabetes mellitus

C.Adrenal crisis

D. Diabetes insipidus

7. The nurse is providing postprocedure care for a client who underwent percutaneous lithotripsy. In this
procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates
ultra-high-frequency sound waves to shatter renal calculi. The nurse should instruct the client to:

A.limit oral fluid intake for 1 to 2 weeks

B.report the presence of fine, sandlike particles through the nephrostomy tube.

C.Notify the physician about cloudy or foul smelling urine

D.Report bright pink urine within 24 hours after the procedure

8. A client with a serum glucose level of 618 mg/dl is admitted to the facility. He’s awake and oriented,
has hot dry skin, and has the following vital signs: temperature of 100.6º F (38.1º C), heart rate of 116
beats/minute, and blood pressure of 108/70 mm Hg. Based on these assessment findings, which nursing
diagnosis takes the highest priority?

A.deficient fluid volume related to osmotic diuresis

B.decreased cardiac output related to elevated heart rate

C.imbalanced nutrition: Less than body requirements related to insulin deficiency

D.ineffective thermoregulation related to dehydration

9. Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic
ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2
p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U of regular insulin. The
nurse should expect the dose’s:
A.onset to be at 2 p.m. and its peak at 3 p.m.

B.onset to be at 2:15 p.m. and its peak at 3 p.m.

C.onset to be at 2:30 p.m. and its peak at 4 p.m.

D.onset to be at 4 p.m. and its peak at 6 p.m.

10. A client with a head injury is being monitored for increased intracranial pressure (ICP). His blood
pressure is 90/60 mmHG and the ICP is 18 mmHg; therefore his cerebral perfusion pressure (CPP) is:

A.52 mm Hg

B.88 mm Hg

C.48 mm Hg

D.68 mm Hg

11. A 52 yr-old female tells the nurse that she has found a painless lump in her right breast during her
monthly self-examination. Which assessment finding would strongly suggest that this client’s lump is
cancerous?

A.eversion of the right nipple and a mobile mass

B.nonmobile mass with irregular edges

C.mobile mass that is oft and easily delineated

D.nonpalpable right axillary lymph nodes

12. A Client is scheduled to have a descending colostomy. He’s very anxious and has many questions
regarding the surgical procedure, care of stoma, and lifestyle changes. It would be most appropriate for
the nurse to make a referral to which member of the health care team?

A.Social worker

B.registered dietician

C.occupational therapist

D.enterostomal nurse therapist

13. Ottorrhea and rhinorrhea are most commonly seen with which type of skull fracture?

A.basilar

B.temporal
C.occipital

D.parietal

14. A male client should be taught about testicular examinations:

A.when sexual activity starts

B.after age 60

C.after age 40

D.before age 20

15. Before weaning a client from a ventilator, which assessment parameter is most important for the
nurse to review?

A.fluid intake for the last 24 hours

B.baseline arterial blood gas (ABG) levels

C.prior outcomes of weaning

D.electrocardiogram (ECG) results

16. The nurse is speaking to a group of women about early detection of breast cancer. The average age
of the women in the group is 47. Following the American Cancer Society (ACS) guidelines, the nurse
should recommend that the women:

A.perform breast self-examination annually

B.have a mammogram annually

C.have a hormonal receptor assay annually

D.have a physician conduct a clinical evaluation every 2 years

17. When caring for a client with esophageal varices, the nurse knows that bleeding in this disorder
usually stems from:

A.esophageal perforation

B.pulmonary hypertension

C.portal hypertension

D.peptic ulcers
18. A 49-yer-old client was admitted for surgical repair of a Colles’ fracture. An external fixator was
placed during surgery. The surgeon explains that this method of repair:

A.has very low complication rate

B.maintains reduction and overall hand function

C.is less bothersome than a cast

D.is best for older people

19. A client is hospitalized with a diagnosis of chronic renal failure. An arteriovenous fistula was created
in his left arm for hemodialysis. When preparing the client for discharge, the nurse should reinforce
which dietary instruction?

A.“Be sure to eat meat at every meal.”

B.“Monitor your fruit intake and eat plenty of bananas.”

C.“Restrict your salt intake.”

D.“Drink plenty of fluids.”

20. The nurse is caring for a client who has just had a modified radical mastectomy with immediate
reconstruction. She’s in her 30s and has tow children. Although she’s worried about her future, she
seems to be adjusting well to her diagnosis. What should the nurse do to support her coping?

A.Tell the client’s spouse or partner to be supportive while she recovers.

B.Encourage the client to proceed with the next phase of treatment.

C.Recommend that the client remain cheerful for the sake of her children.

D.Refer the client to the American Cancer Society’s Reach for Recovery program or another support
program.

21. A 21 year-old male has been seen in the clinic for a thickening in his right testicle. The physician
ordered a human chorionic gonadotropin (HCG) level. The nurse’s explanation to the client should
include the fact that:

A.The test will evaluate prostatic function.

B.The test was ordered to identify the site of a possible infection.

C.The test was ordered because clients who have testicular cancer has elevated levels of HCG.

D.The test was ordered to evaluate the testosterone level.

22. A client is receiving captopril (Capoten) for heart failure. The nurse should notify the physician that
the medication therapy is ineffective if an assessment reveals:

A.A skin rash.

B.Peripheral edema.

C.A dry cough.

D.Postural hypotension.

23. Which assessment finding indicates dehydration?

A.Tenting of chest skin when pinched.

B.Rapid filling of hand veins.

C.A pulse that isn’t easily obliterated.

D.Neck vein distention

24. The nurse is teaching a client with a history of atherosclerosis. To decrease the risk of atherosclerosis,
the nurse should encourage the client to:

A.Avoid focusing on his weight.

B.Increase his activity level.

C.Follow a regular diet.

D.Continue leading a high-stress lifestyle.

25. For a client newly diagnosed with radiationinduced thrombocytopenia, the nurse should include
which intervention in the plan of care?

A.Administer aspirin if the temperature exceeds 38.8º C.

B.Inspect the skin for petechiae once every shift.

C.Provide for frequent periods of rest.

D.Place the client in strict isolation.

26. A client is chronically short of breath and yet has normal lung ventilation, clear lungs, and an arterial
oxygen saturation (SaO2) 96% or better. The client most likely has:

A.poor peripheral perfusion

B.a possible Hematologic problem

C.a psychosomatic disorder

D.left-sided heart failure

27. For a client in addisonian crisis, it would be very risky for a nurse to administer:

A.potassium chloride

B.normal saline solution

C.hydrocortisone

D.fludrocortisone

28. The nurse is reviewing the laboratory report of a client who underwent a bone marrow biopsy. The
finding that would most strongly support a diagnosis of acute leukemia is the existence of a large
number of immature:

A.lymphocytes

B.thrombocytes

C.reticulocytes

D.leukocytes

29. The nurse is performing wound care on a foot ulcer in a client with type 1 diabetes mellitus. Which
technique demonstrates surgical asepsis?

A.Putting on sterile gloves then opening a B.container of sterile saline.

C.Cleaning the wound with a circular motion, moving from outer circles toward the center.

D.Changing the sterile field after sterile water is spilled on it.

E.Placing a sterile dressing ½” (1.3 cm) from the edge of the sterile field.

30. A client with a forceful, pounding heartbeat is diagnosed with mitral valve prolapse. This client
should avoid which of the following?

A.high volumes of fluid intake

B.aerobic exercise programs

C.caffeine-containing products

D.foods rich in protein

31. A client with a history of hypertension is diagnosed with primary hyperaldosteronism. This diagnosis
indicates that the client’s hypertension is caused by excessive hormone secretion from which organ?

A.adrenal cortex

B.pancreas

C.adrenal medulla

D.parathyroid

32. A client has a medical history of rheumatic fever, type 1 (insulin dependent) diabetes mellitus,
hypertension, pernicious anemia, and appendectomy. She’s admitted to the hospital and undergoes
mitral valve replacement surgery. After discharge, the client is scheduled for a tooth extraction. Which
history finding is a major risk factor for infective endocarditis?

A.appendectomy

B.pernicious anemia

C.diabetes mellitus

D.valve replacement

33. A 62 yr-old client diagnosed with pyelonephritis and possible septicemia has had five urinary tract
infections over the past two years. She’s fatigued from lack of sleep; urinates frequently, even during the
night; and has lost weight recently. Test reveal the following: sodium level 152 mEq/L, osmolarity 340
mOsm/L, glucose level 125 mg/dl, and potassium level 3.8 mEq/L. which of the following nursing
diagnoses is most appropriate for this client?

A.Deficient fluid volume related to inability to conserve water

B.Imbalanced nutrition: less than body requirements related to hypermetabolic state

C.Deficient fluid volume related to osmotic diuresis induced by hypernatremia

D.Imbalanced nutrition: less than body requirements related to catabolic effects of insulin deficiency

34. A 20 yr-old woman has just been diagnosed with Crohn’s disease. She has lost 10 lb (4.5 kg) and has
cramps and occasional diarrhea. The nurse should include which of the following when doing a
nutritional assessment?

A.Let the client eat as desired during the hospitalization.

B.Weight the client daily.

C.Ask the client to list what she eats during a typical day.
D.Place the client on I & O status and draw blood for electrolyte levels.

35. When instructions should be included in the discharge teaching plan for a client after thyroidectomy
for Grave’s disease?

A.Keep an accurate record of intake and output.

B.Use nasal desmopressin acetate DDAVP).

C.Be sure to get regulate follow-up care.

D.Be sure to exercise to improve cardiovascular fitness.

36. A client comes to the emergency department with chest pain, dyspnea, and an irregular heartbeat.
An electrocardiogram shows a heart rate of 110 beats/minute (sinus tachycardia) with frequent
premature ventricular contractions. Shortly after admission, the client has ventricular tachycardia and
becomes unresponsive. After successful resuscitation, the client is taken to the intensive care unit.
Which nursing diagnosis is appropriate at this time?

A.Deficient knowledge related to interventions used to treat acute illness

B.Impaired physical mobility related to complete bed rest

C.Social isolation related to restricted visiting hours in the intensive care unit

D.Anxiety related to the threat of death

37. A client is admitted to the health care facility with active tuberculosis. The nurse should include
which intervention in the plan of care?

A.Putting on a mask when entering the client’s room.

B.Instructing the client to wear a mask at all times

C.Wearing a gown and gloves when providing direct care

D.Keeping the door to the client’s room open to observe the client

38. The nurse is caring for a client who underwent a subtotal gastrectomy 24 hours earlier. The client has
a nasogastric (NG) tube. The nurse should:

A.Apply suction to the NG tube every hour.

B.Clamp the NG tube if the client complains of nausea.

Irrigate the NG tube gently with normal C.saline solution.

D.Reposition the NG tube if pulled out.

39. Which statement about fluid replacement is accurate for a client with hyperosmolar hyperglycemic
nonketotic syndrome (HHNS)?

A.administer 2 to 3 L of IV fluid rapidly

B.administer 6 L of IV fluid over the first 24 hours

C.administer a dextrose solution containing normal saline solution

D.administer IV fluid slowly to prevent circulatory overload and collapse

40. Which of the following is an adverse reaction to glipizide (Glucotrol)?

A.headache

B.constipation

C.hypotension

D.photosensitivity

41. The nurse is caring for four clients on a stepdown intensive care unit. The client at the highest risk for
developing nosocomial pneumonia is the one who:

A.has a respiratory infection

B.is intubated and on a ventilator

C.has pleural chest tubes

D.is receiving feedings through a jejunostomy tube

42. The nurse is teaching a client with chronic bronchitis about breathing exercises. Which of the
following should the nurse include in the teaching?

A.Make inhalation longer than exhalation.

B.Exhale through an open mouth.

C.Use diaphragmatic breathing.

D.Use chest breathing.

43. A client is admitted to the hospital with an exacerbation of her chronic systemic lupus erythematosus
(SLE). She gets angry when her call bell isn’t answered immediately. The most appropriate response to
her would be:

A.“You seem angry. Would you like to talk about it?”

B.“Calm down. You know that stress will make your symptoms worse.”

C.“Would you like to talk about the problem with the nursing supervisor?”

D.“I can see you’re angry. I’ll come back when you’ve calmed down.”

44. On a routine visit to the physician, a client with chronic arterial occlusive disease reports stopping
smoking after 34 years. To relive symptoms of intermittent claudication, a condition associated with
chronic arterial occlusive disease, the nurse should recommend which additional measure?

A.Taking daily walks.

B.Engaging in anaerobic exercise.

C.Reducing daily fat intake to less than 45% of total calories

D.Avoiding foods that increase levels of highdensity lipoproteins (HDLs)

45. A physician orders gastric decompression for a client with small bowel obstruction. The nurse should
plan for the suction to be:

A.low pressure and intermittent

B.low pressure and continuous

C.high pressure and continuous

D.high pressure and intermittent

46. Which nursing diagnosis is most appropriate for an elderly client with osteoarthritis?

A.Risk for injury

B.Impaired urinary elimination

C.Ineffective breathing pattern

D.Imbalanced nutrition: less than body requirements

47. Parathyroid hormone (PTH) has which effects on the kidney?

A.Stimulation of calcium reabsorption and phosphate excretion

B.Stimulation of phosphate reabsorption and calcium excretion

C.Increased absorption of vit D and excretion of vit E

D.Increased absorption of vit E and excretion of Vit D

48. A visiting nurse is performing home assessment for a 59-yr old man recently discharged after hip
replacement surgery. Which home assessment finding warrants health promotion teaching from the
nurse?

A.A bathroom with grab bars for the tub and toilet

B.Items stored in the kitchen so that reaching up and bending down aren’t necessary

C.Many small, unsecured area rugs

D.Sufficient stairwell lighting, with switches to the top and bottom of the stairs

49. A client with autoimmune thrombocytopenia and a platelet count of 800/uL develops epistaxis and
melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician
recommends a splenectomy. The client states, “I don’t need surgery—this will go away on its own.” In
considering her response to the client, the nurse must depend on the ethical principle of:

A.beneficence

B.autonomy

C.advocacy

D.justice

50. Which of the following is t he most critical intervention needed for a client with myxedema coma?

A.Administering and oral dose of levothyroxine (Synthroid)

B.Warming the client with a warming blanket

C.Measuring and recording accurate intake and output

D.Maintaining a patent airway

51. Because diet and exercise have failed to control a 63 yr-old client’s blood glucose level, the client is
prescribed glipizide (Glucotrol). After oral administration, the onset of action is:

A.15 to 30 minutes

B.30 to 60 minutes

C.1 to 1 ½ hours

D.2 to 3 hours

52. A client with pneumonia is receiving supplemental oxygen, 2 L/min via nasal cannula. The client’s
history includes chronic obstructive pulmonary disease (COPD) and coronary artery disease. Because of
these findings, the nurse closely monitors the oxygen flow and the client’s respiratory status. Which
complication may arise if the client receives a high oxygen concentration?

A.Apnea

B.Anginal pain

C.Respiratory alkalosis

D.Metabolic acidosis

53. A client with type 1 diabetes mellitus has been on a regimen of multiple daily injection therapy. He’s
being converted to continuous subcutaneous insulin therapy. While teaching the client bout continuous
subcutaneous insulin therapy, the nurse would be accurate in telling him the regimen includes the use
of:

A.intermediate and long-acting insulins

B.short and long-acting insulins

C.short-acting only

D.short and intermediate-acting insulins

54. a client who recently had a cerebrovascular accident requires a cane to ambulate. When teaching
about cane use, the rationale for holding a cane on the uninvolved side is to:

A.prevent leaning

B.distribute weight away from the involved side

C.maintain stride length

D.prevent edema

55. A client with a history of an anterior wall myocardial infarction is being transferred from the coronary
care unit (CCU) to the cardiac stepdown unit (CSU). While giving report to the CSU nurse, the CCU nurse
says, “His pulmonary artery wedge pressures have been in the high normal range.” The CSU nurse should
be especially observant for:

A.hypertension

B.high urine output

C.dry mucous membranes

D.pulmonary crackles
56. The nurse is caring for a client with a fractures hip. The client is combative, confused, and trying to
get out of bed. The nurse should:

A.leave the client and get help

B.obtain a physician’s order to restrain the client

C.read the facility’s policy on restraints

D.order soft restraints from the storeroom

57. For the first 72 hours after thyroidectomy surgery, the nurse would assess the client for Chvostek’s
sign and Trousseau’s sign because they indicate which of the following?

A.hypocalcemia

B.hypercalcemia

C.hypokalemia

D.Hyperkalemia

58. In a client with enteritis and frequent diarrhea, the nurse should anticipate an acidbase imbalance of:

A.respiratory acidosis

B.respiratory alkalosis

C.metabolic acidosis

D.metabolic alkalosis

59. When caring for a client with the nursing diagnosis Impaired swallowing related to neuromuscular
impairment, the nurse should:

A.position the client in a supine position

B.elevate the head of the bed 90 degrees during meals

C.encourage the client to remove dentures

D.encourage thin liquids for dietary intake

60. A nurse is caring for a client who has a tracheostomy and temperature of 39º C. which intervention
will most likely lower the client’s arterial blood oxygen saturation?

A.Endotracheal suctioning

B.Encouragement of coughing
C.Use of cooling blanket

D.Incentive spirometry

61. A client with a solar burn of the chest, back, face, and arms is seen in urgent care. The nurse’s
primary concern should be:

A.fluid resuscitation

B.infection

C.body image

D.pain management

62. Which statement is true about crackles?

A.They’re grating sounds.

B.They’re high-pitched, musical squeaks.

C.They’re low-pitched noises that sound like snoring.

D.They may be fine, medium, or course.

63. A woman whose husband was recently diagnosed with active pulmonary tuberculosis (TB) is a
tuberculin skin test converter. Management of her care would include:

A.scheduling her for annual tuberculin skin testing

B.placing her in quarantine until sputum cultures are negative

C.gathering a list of persons with whom she has had recent contact

D.advising her to begin prophylactic therapy with isoniazid (INH)

64. The nurse is caring for a client who ahs had an above the knee amputation. The client refuses to look
at the stump. When the nurse attempts to speak with the client about his surgery, he tells the nurse that
he doesn’t wish to discuss it. The client also refuses to have his family visit. The nursing diagnosis that
best describes the client’s problem is:

A.Hopelessness

B.Powerlessness

C.Disturbed body image

D.Fear
65. A client with three children who is still I the child bearing years is admitted for surgical repair of a
prolapsed bladder. The nurse would find that the client understood the surgeon’s preoperative teaching
when the client states:

A.“If I should become pregnant again, the child would be delivered by cesarean delivery.”

B.“If I have another child, the procedure may need to be repeated.”

C.“This surgery may render me incapable of conceiving another child.”

D.“This procedure is accomplished in two separate surgeries.”

66. A client experiences problems in body temperature regulation associated with a skin impairment.
Which gland is most likely involved?

A.Eccrine

B.Sebaceous

C.Apocrine

D.Endocrine

67. A school cafeteria worker comes to the physician’s office complaining of severe scalp itching. On
inspection, the nurse finds nail marks on the scalp and small light-colored round specks attached to the
hair shafts close to the scalp. These findings suggest that the client suffers from:

A.scabies

B.head lice

C.tinea capitis

D.impetigo

68. Following a small-bowel resection, a client develops fever and anemia. The surface surrounding the
surgical wound is warm to touch and necrotizing fasciitis is suspected. Another manifestation that would
most suggest necrotizing fasciitis is:

A.erythema

B.leukocytosis

C.pressure-like pain

D.swelling

69. A 28 yr-old nurse has complaints of itching and a rash of both hands. Contact dermatitis is initially
suspected. The diagnosis is confirmed if the rash appears:
A.erythematous with raised papules

B.dry and scaly with flaking skin

C.inflamed with weeping and crusting lesions

D.excoriated with multiple fissures

70. When assessing a client with partial thickness burns over 60% of the body, which of the following
should the nurse report immediately?

A.Complaints of intense thirst

B.Moderate to severe pain

C.Urine output of 70 ml the 1st hour

D.Hoarseness of the voice

71. A client is admitted to the hospital following a burn injury to the left hand and arm. The client’s burn
is described as white and leathery with no blisters. Which degree of severity is this burn?

A.first-degree burn

B.second-degree burn

C.third-degree burn

D.fourth-degree burn

72. The nurse is caring for client with a new donor site that was harvested to treat a new burn. The nurse
position the client to:

A.allow ventilation of the site

B.make the site dependent

C.avoid pressure on the site

D.keep the site fully covered

73. a 45-yr-old auto mechanic comes to the physician’s office because an exacerbation of his psoriasis is
making it difficult to work. He tells the nurse that his finger joints are stiff and sore in the morning. The
nurse should respond by:

A.Inquiring further about this problem because psoriatic arthritis can accompany psoriasis vulgaris

B.Suggesting he take aspirin for relief because it’s probably early rheumatoid arthritis
C.Validating his complaint but assuming it’s an adverse effect of his vocation

D.Asking him if he has been diagnosed or treated for carpal tunnel syndrome

74. The nurse is providing home care instructions to a client who has recently had a skin graft. Which
instruction is most important for the client to remember?

A.Use cosmetic camouflage techniques.

B.Protect the graft from direct sunlight.

C.Continue physical therapy.

D.Apply lubricating lotion to the graft site.

75. a 28 yr-old female nurse is seen in the employee health department for mild itching and rash of both
hands. Which of the following could be causing this reaction?

A.possible medication allergies

B.current life stressors she may be experiencing

C.chemicals she may be using and use of latex gloves

D.recent changes made in laundry detergent or bath soap.

76. The nurse assesses a client with urticaria. The nurse understands that urticaria is another name for:

A.hives

B.a toxin

C.a tubercle

D. a virus

77. A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse
expects to see which type of secondary lesion?

A.scale

B.crust

C.ulcer

D.scar

78. The nurse is caring for a bedridden, elderly adult. To prevent pressure ulcers, which intervention
should the nurse include in the plan of care?
A.Turn and reposition the client a minimum of every 8 hours.

B.Vigorously massage lotion into bony prominences.

C.Post a turning schedule at the client’s bedside.

D.Slide the client, rather than lifting when turning.

79. Following a full-thickeness (3rd degree) burn of his left arm, a client is treated with artificial skin. The
client understands postoperative care of the artificial skin when he states that during the first 7 days
after the procedure, he’ll restrict:

A.range of motion

B.protein intake

C.going outdoors

D.fluid ingestion

80. A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can
calculate that he has sustained burns on what percentage of his body?

A.9%

B.18%

C.27%

D.36%

81. The nurse is providing care for a client who has a sacral pressure ulcer with wet-to-dry dressing.
Which guideline is appropriate for a wet-to-dry dressing?

A.The wound should remain moist form the dressing.

B.The wet-to-dry dressing should be tightly packed into the wound.

C.The dressing should be allowed to dry out before removal.

D.A plastic sheet-type dressing should cover the wet dressing.

82. While in skilled nursing facility, a client contracted scabies, which is diagnosed the day after
discharge. The client is living at her daughter’s home with six other persons. During her visit to the clinic,
she asks a staff nurse, “What should my family do?” the most accurate response from the nurse is:

A.“All family members will need to be treated.”

B.“If someone develops symptoms, tell him to see a physician right away.”
C.“Just be careful not to share linens and towels with family members.”

D.“After you’re treated, family members won’t be at risk for contracting scabies.”

83. In an industrial accident, client who weighs 155 lb (70.3 kg) sustained full-thickness burns over 40%
of his body. He’s in the burn unit receiving fluid resuscitation. Which observation shows that the fluid
resuscitation is benefiting the client?

A.A urine output consistently above 100 ml/hour.

B.A weight gain of 4 lb (1.8 kg) in 24 hours.

C.Body temperature readings all within normal limits

D.An electrocardiogram (ECG) showing no arrhythmias.

84. The nurse is reviewing the laboratory results of a client with rheumatoid arthritis. Which of the
following laboratory results should the nurse expect to find?

A.Increased platelet count

B.Elevated erythrocyte sedimentation rate (ESR)

C.Electrolyte imbalance

D.Altered blood urea nitrogen (BUN) and creatinine levels

85. Which nursing diagnosis takes the highest priority for a client with Parkinson’s crisis?

A.Imbalanced nutrition: less than body requirements

B.Ineffective airway clearance

C.Impaired urinary elimination

D.Risk for injury

86. A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization
every 4 hours. The average catheterized urine volume has been 550 ml. The nurse should plan to:

A.Increase the frequency of the catheterizations.

B.Insert an indwelling urinary catheter

C.Place the client on fluid restrictions

Use a condom catheter instead of an D.invasive one.

87.The nurse is caring for a client who is to undergo a lumbar puncture to assess for the presence of
blood in the cerebrospinal fluid (CSF) and to measure CSF pressure. Which result would indicate n
abnormality?

A.The presence of glucose in the CSF.

B.A pressure of 70 to 200 mm H2O

C.The presence of red blood cells (RBCs) in the first specimen tube

D.A pressure of 00 to 250 mmH2O

88. The nurse is administering eyedrops to a client with glaucoma. To achieve maximum absorption, the
nurse should instill the eyedrop into the:

A.A conjunctival sac

B.pupil

C.sclera

D.vitreous humor

89. A 52 yr-old married man with two adolescent children is beginning rehabilitation following a
cerebrovascular accident. As the nurse is planning the client’s care, the nurse should recognize that his
condition will affect:

A.only himself

B.only his wife and children

C.him and his entire family

D.no one, if he has complete recovery

90. Which action should take the highest priority when caring for a client with hemiparesis caused by a
cerebrovascular accident (CVA)?

A.Perform passive range-of-motion (ROM) exercises.

B.Place the client on the affected side.

C.Use hand rolls or pillows for support.

D.Apply antiembolism stockings

91. The nurse is formulating a teaching plan for a client who has just experienced a transient ischemic
attack (TIA). Which fact should the nurse include in the teaching plan?
A.TIA symptoms may last 24 to 48 hours.

B.Most clients have residual effects after having a TIA.

C.TIA may be a warning that the client may have cerebrovascular accident (CVA)

D.The most common symptom of TIA is the inability to speak.

92. The nurse has just completed teaching about postoperative activity to a client who is going to have a
cataract surgery. The nurse knows the teaching has been effective if the client:

A.coughs and deep breathes postoperatively

B.ties his own shoes

C.asks his wife to pick up his shirt from the floor after he drops it.

D.States that he doesn’t need to wear an eyepatch or guard to bed

93. The least serious form of brain trauma, characterized by a brief loss of consciousness and period of
confusion, is called:

A.contusion

B.concussion

C.coup

D.contrecoup

94. When the nurse performs a neurologic assessment on Anne Jones, her pupils are dilated and don’t
respond to light.

A.glaucoma

B.damage to the third cranial nerve

C.damage to the lumbar spine

D.Bell’s palsy

95. A 70 yr-old client with a diagnosis of leftsided cerebrovascular accident is admitted to the facility. To
prevent the development of diffuse osteoporosis, which of the following objectives is most appropriate?

A.Maintaining protein levels.

B.Maintaining vitamin levels.

C.Promoting weight-bearing exercises

D.Promoting range-of-motion (ROM) exercises

96. A client is admitted with a diagnosis of meningitis caused by Neisseria meningitides. The nurse
should institute which type of isolation precautions?

A.Contact precautions

B.Droplet precautions

C.Airborne precautions

D.Standard precautions

97. A young man was running along an ocean pier, tripped on an elevated area of the decking, and struck
his head on the pier railing. According to his friends, “He was unconscious briefly and then became alert
and behaved as though nothing had happened.” Shortly afterward, he began complaining of a headache
and asked to be taken to the emergency department. If the client’s intracranial pressure (ICP) is
increasing, the nurse would expect to observe which of the following signs first?

A.pupillary asymmetry

B.irregular breathing pattern

C.involuntary posturing

D.declining level of consciousness

98. Emergency medical technicians transport a 28 yr-old iron worker to the emergency department. They
tell the nurse, “He fell from a two-story building. He has a large contusion on his left chest and a
hematoma in the left parietal area. He has compound fracture of his left femur and he’s comatose. We
intubated him and he’s maintaining an arterial oxygen saturation of 92% by pulse oximeter with a
manual-resuscitation bag.” Which intervention by the nurse has the highest priority?

A.Assessing the left leg

B.Assessing the pupils

C.Placing the client in Trendelenburg’s position

D.Assessing the level of consciousness

99. Alzheimer’s disease is the secondary diagnosis of a client admitted with myocardial infarction. Which
nursing intervention should appear on this client’s plan of care?

A.Perform activities of daily living for the client to decease frustration.

B.Provide a stimulating environment.

C.Establish and maintain a routine.

D.Try to reason with the client as much as possible.

100. For a client with a head injury whose neck has been stabilized, the preferred bed position is:

A.Trendelenburg’s

B.30-degree head elevation

C.flat

D.side-lying