PN Fundamentals of Nursing Online Practice PA

PN Fundamentals of Nursing Online Practice PA
1. A nurse is caring for a client who has a prescription for a stool guaiac test. The client asks the nurse about the
purpose of the test. The nurse should respond by stating that the stool guaiac is testing for which of the following?
A. Bacteria
B. Parasites
C. Blood
D. Fat
2. A nurse is evaluating a client who sustained severe burn injuries in a grease fire. The nurse shades in the diagram
indicating the burned surface areas. What percentage of body surface area does the nurse estimate the client has
burned?
______ %
3. A nurse is collecting data from a client who has a possible cataract. The nurse expects the client to report
A. decreased color perception.
B. loss of peripheral vision.
C. bright flashes of light and floaters.
D. eyestrain and headache.
4. A nurse is caring for an older adult client hospitalized with delirium. Which of the following statements by the client's
daughter is typical of delirium?
A. "The change in behavior came on so quickly, I wasn't sure what was happening to her."
B. "Maybe the behavior is age-related."
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C. "She just didn't seem to know what she was doing. She would forget what she had for breakfast."
D. "She has always been so independent. She's lived alone since my father died years ago."
5. A nurse is collecting data from a client who has had scleroderma (systemic sclerosis) for 5 years. In addition to skin
changes, which finding should the nurse expect?
A. Alopecia
B. Excessive salivation
C. Periorbital edema
D. Finger contractures
6. A nurse is caring for an older adult client who has weakness on her left side due to a cerebrovascular accident.
She becomes upset when eating, because liquids seep out of her mouth on the weak side. Which of the following
nursing interventions is appropriate?
A. Provide only pureed and solid foods.
B. Have a family member feed the client.
C. Add thickener to fluids to increase their consistency.
D. Have the client use a syringe to squirt liquids into the back of her mouth.
7. A nurse is reinforcing teaching for a client discharged from the hospital after treatment for poor circulation in the
lower extremities. Which of the following statements by the client indicates a need for further teaching?
A. "I will avoid crossing my legs at the knees."
B. "I will use a thermometer to check the temperature of my bath water."
C. "I will wear shoes instead of sandals."
D. "I will wear stockings with elastic tops."
8. A nurse is caring for a client who is postoperative following a mastectomy and returns to the surgical unit with a
closed-wound drainage system in place. Which of the following actions by the nurse ensures proper operation of
the device?
A. Recollapse the reservoir immediately after emptying it.
B. Empty the reservoir when it becomes full.

C. Replace the drainage plug after releasing hand pressure on the device.
D. Irrigate the tubing with sterile normal saline solution at least every 8 hr.
9. The nurse is collecting data from a client who had left femoral cardiac angiography. Identify the area the nurse will
palpate to monitor the most distal pulse on the affected side. (Selectable areas, or “Hot Spots,” are outlined in the
artwork below. Select only the outlined area that corresponds to your answer.)
Answers cannot be displayed for this alternate item format.
10. A nurse is caring for a client in the prenatal clinic who is at 7 weeks of gestation. The client reports urinary
frequency and asks the nurse if this will continue throughout her pregnancy. Which of the following is an
appropriate response?
A. "Yes, it will, but if you decrease your fluid intake, especially at bedtime, it won't be so bothersome."
B. "No, in most cases it only lasts until about the 12th week, but it will continue if you have poor bladder tone."
C. "There is no way to predict how long it will last for each individual client, so you'll just have to wait and see."
D. "No, it should only last until about your 12th week, but it will return near the end of the pregnancy."
11. A nurse is caring for a client with a spinal cord injury at level C-8 who is admitted for comprehensive rehabilitation.
Which of the following long-term goals is appropriate with regard to the client's mobility?
A. Walk with leg braces and crutches.
B. Drive an electric wheelchair with a hand-control device.
C. Drive an electric wheelchair equipped with a chin-control device.
D. Propel a wheelchair equipped with knobs on the wheels.

12. A nurse checks a postpartum client's perineal pad and finds a large amount of rubra lochia with several clots.
Which of the following is the priority nursing action?
A. Recommend a complete vaginal examination.
B. Feel for a full bladder.
C. Measure the client's vital signs.
D. Check the client's fundus.
13. A nurse is caring for a client who has an exacerbation of gout. When collecting data from the client, which of the
following joint alterations should the nurse expect to observe? (Select all that apply.)
A. Hyperemia
B. Erythema
C. Tophi
D. Decreased mobility
E. Symmetrical joint pain
F. Swollen glands
14. A nurse in a clinic is collecting data from a client who has AIDS. When checking the client's mouth, the nurse
notes a white creamy covering on the tongue and buccal membranes. The nurse recognizes this as a
manifestation of
A. xerostomia.
B. gingivitis.
C. candidiasis.
D. halitosis.
15. A nurse is assigned to provide care to four clients who have drainage tubes. Which of the following clients should
the nurse recognize is at risk for hypokalemia?
A. A client who has an NG tube to suction
B. A client who has an indwelling urinary catheter to gravity
C. A client who has a chest tube to water seal
D. A client who has a nephrostomy tube to a drainage bag

16. A nurse is caring for a client admitted with major burns of the head, neck, and chest. In planning the client's care,
the nurse is aware that the client is at the greatest risk for
A. hypothermia.
B. hyponatremia.
C. fluid imbalance.
D. airway obstruction.
17. A nurse is assisting with planning care for a client who is 4 days postoperative following a right radical
mastectomy. The nurse should expect that the client will be unable to perform which of the following activities with
her right hand?
A. Combing her hair
B. Eating her breakfast
C. Buttoning her blouse
D. Brushing her teeth
18. A nurse is caring for a client who has a wound. The nurse should recognize that which of the following findings is
indicative of a wound infection?
A. Copious serosanguineous drainage from the wound
B. Swelling and tenderness around the wound
C. Maculopapular rash and itching around the wound
D. Brownish-green crusting over the wound
19. A nurse is speaking to the partner of an older adult client who resides in an long-term care facility. The partner
reports that he has had to speak louder than usual for his spouse to be able to hear him. The client has also
stopped actively participating in social activities and group conversations. The nurse should recognize that these
findings are likely due to which of the following?
A. Mastoiditis
B. Presbycusis
C. Presbyopia
D. Otomycosis

20. A nurse is reinforcing teaching to a pregnant client who is to undergo an ultrasound immediately prior to an
amniocentesis. The nurse explains that the reason for the ultrasound is to determine which of the following?
A. Gestational age of the fetus
B. Location of the fetus and placenta
C. Amount of amniotic fluid
D. Degree of fetal lung maturity
21. A nurse is caring for a client diagnosed with rheumatoid arthritis. When performing assisted range of motion on the
client's joints, the nurse is likely to note the presence of which of the following?
A. Heberden’s nodules
B. Tophi
C. Boutonniere deformity
D. Osteoma
22. A nurse is planning caring for a client who has thrombocytopenia. The nurse understands that the client’s plan of
care should include which of the following?
A. Restricting visitors to family members only
B. Avoiding venipunctures whenever possible
C. Limiting oral fluid intake to between meals
D. Prohibiting fresh flowers in the client’s room
23. A nurse working in a pediatric clinic is collecting data on a preschool-age child who has a rash on his arm. The
mother reports that the child was recently exposed to impetigo contagiosa. Which of the following manifestations
should the nurse expect to find with this skin infection?
A. Scaling patches that are clear in the center.
B. Honey-colored crusts caused by dried exudate.
C. Firm papules with a roughened, finely papillomatous texture.
D. Lines of small blisters surrounding one large blister.

24. A nurse is collecting data from an infant who has hypertrophic pyloric stenosis. Which of the following findings
should the nurse expect?
A. Projectile vomiting
B. Bile colored vomit
C. Absent bowel sounds
D. Indifferent approach to feedings
25. A nurse is caring for a client who has gestational diabetes and reports feeling shaky, sweaty, and blurred vision.
The client’s blood glucose level is 48 mg/dL. Which of the following is appropriate to give the client? (Select all that
apply).
A. 120 mL unsweetened fruit juice
B. 1 tbsp honey
C. 5 hard candies
D. 240 mL regular soda
E. 120 mL milk
26. A nurse is collecting data from a child after a tonsillectomy. Which of the following is a clinical manifestation of a
hemorrhage?
A. Increased pain
B. Poor fluid intake
C. Drooling
D. Continuous swallowing
27. A nurse suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which
of the following is the priority intervention?
A. Insert an IV line.
B. Count the respiratory rate.
C. Administer oxygen.
D. Prepare equipment for intubation.

28. A nurse is assisting with an admission assessment on a client. Which of the following findings should the nurse
report to the charge nurse as an indicator of dehydration?
A. Red mucous membranes
B. Jugular vein distention
C. Skin tenting present
D. Blood pressure 178/90 mm Hg
29. A nurse is evaluating the laboratory report for a client who is receiving treatment for a high fever and a viral
infection. Which of the following is an expected finding?
A. Elevated T-cell count
B. Decreased leukocyte count
C. Elevated hemoglobin level
D. Decreased albumin level
30. A nurse is reinforcing teaching with an older adult client who has just undergone insertion of a permanent
pacemaker. The nurse should emphasize that a sign of pacemaker malfunction the client should report to the
provider is
A. increased urine output.
B. rapid pulse.
C. fatigue.
D. sneezing.
31. A nurse is caring for a client who has developed atelectasis postoperatively. Which of the following findings should
the nurse expect?
A. Facial flushing
B. Increasing dyspnea
C. Decreasing respiratory rate
D. Dry cough

32. A nurse is caring for an infant who has hydrocephalus. Which of the following manifestations should the nurse
expect to find?
A. Proteinuria
B. Dilated scalp veins
C. Hypertension
D. Pulsatile fontanels
33. A client with a long history of ulcerative colitis has anemia. The nurse should explain to the client that which of the
following manifestations of colitis is likely to result in anemia?
A. Decreased iron in the client’s diet
B. Intestinal malabsorption syndrome
C. Chronic blood loss
D. Intestinal parasites
34. A nurse is talking with a client who will undergo surgery to repair retinal detachment. Which of the following
preoperative instructions should the nurse include?
A. Keep both eyes patched.
B. Restrict head movement.
C. Lie down as much as possible.
D. Apply cool compresses.
35. A nurse is assessing a client who has COPD. The nurse should expect the client’s chest to be which of the
following shapes?
A. Pigeon
B. Funnel
C. Kyphotic
D. Barrel

36. A nurse is planning preventative care for a client who had a traumatic brain injury and is emerging restlessly from
a coma. Which of the following is an appropriate nursing action?
A. Apply restraints.
B. Administer opioids.
C. Darken the room.
D. Reduce stimuli.
37. A nurse is caring for a client who has chronic renal failure. Which of the following is an expected laboratory
finding?
A. Hypokalemia.
B. Decreased urine specific gravity.
C. Decreased BUN.
D. Elevated creatinine.
38. A nurse is preparing a client for a kidney biopsy. Which of the following should the nurse identify as a
contraindication for this diagnostic test?
A. Active kidney infection.
B. Current flank pain.
C. Urinary retention.
D. Bleeding tendencies.
39. A nurse is caring for a client who has benign prostatic hyperplasia (BPH). Which of the following is an expected
finding?
A. Urge incontinence.
B. Critically elevated prostate-specific antigen (PSA) level.
C. Difficulty starting the flow of urine.
D. Painful urination.
40. A nurse is caring for a client who has polycystic kidney disease (PKD). Which of the following is an expected

finding?
A. Flank pain.
B. Hypotension.
C. Confusion.
D. Poor skin turgor.
41. A nurse is discussing the phases of acute kidney injury with a client. The nurse should identify that the phases
occur in which order? (Place the phases of acute kidney injury in the order that they occur. All phases must be
used.)
A. Diuretic phase.
B. Onset phase.
C. Oliguric phase.
D. Recovery phase.
42. A nurse is teaching a client who has recurrent urinary tract infections (UTIs) about prevention measures. Which of
the following client statements indicates the need for further teaching?
A. “I will need to wipe my perineal area from back to front after urination.”
B. “I will need to empty my bladder regularly and completely.”
C. “I will need to evacuate my bowels regularly.”
D. “I need to drink an adequate amount of liquid each day.”
43. A nurse is reinforcing teaching for a client who has a new diagnosis of atopic dermatitis. Which of the following
statements is appropriate for the nurse to include?
A. "You will need to take the entire prescription of antibiotics even if your symptoms improve."
B. "Your provider may recommend a daily antihistamine to help control your symptoms."
C. "You should thoroughly cleanse your mouth with a prescribed mouthwash after each meal."
D. "Your provider will remove the lesions with liquid nitrogen."
44. A nurse is caring for a client who has herpes zoster. Which of the following is an appropriate intervention?

A. Apply dry, sterile gauze dressings to affected areas.
B. Prepare to administer acyclovir (Zovirax).
C. Instruct family with a history of chickenpox that they are still at risk for contracting the virus.
D. Apply topical corticosteroids to the affected areas.
45. A nurse is reinforcing teaching for a client who has herpes zoster. The nurse should include which of the
following?
A. Inform the client that herpes zoster is only contagious to others who have had chickenpox.
B. Inform the client that they are contagious only if the lesions are draining.
C. Recurrence of infection can be triggered by stress and fatigue.
D. With recurrence of infection, vesicles will appear before the pain begins.
46. A nurse is planning to reinforce teaching for the client who has psoriasis. Which of the following is appropriate to
include?
A. Maintain occlusive dressings on the lesions throughout the day.
B. Eliminate the use of products containing salicylic acid.
C. Avoid friction over scaly lesions while bathing.
D. Identify effective stress reduction techniques.
47. A nurse is teaching a client who has herpes zoster about the order of occurrence of findings associated with this
disorder. The nurse should identify the typical occurrence of findings in which order? (Identify the occurrence of
findings in the appropriate order of appearance. All findings must be used.)
A. Crusted lesions
B. Paresthesia
C. Postherpetic neuralgia
D. Redness and swelling
E. Vesicles
F. Weeping blisters

48. A nurse is caring for a toddler whose parent states while bathing the child she noticed a mass in his abdominal
area and his urine is a pink color. Which of the following is the priority action the nurse should take?
A. Schedule the child for an abdominal ultrasound.
B. Instruct the parent to avoid pressing on the abdominal area.
C. Determine if the child is having pain.
D. Obtain a urine specimen for a urinalysis.
49. A nurse is caring for a client who has a fractured right femur and is in balanced suspension traction. The client will
be in which of the following positions?
A. Supine and both legs extended
B. With the right leg flat on the bed
C. Semi-Fowler’s with the legs elevated to 10°
D. With the right leg at a 20°angle
50. A nurse is reinforcing teaching to the mother of an infant born small for gestational age. Which of the following
should the nurse include as a cause of this condition?
A. Placental insufficiency
B. Maternal obesity
C. Primipara
D. Perinatal asphyxia
51. A nurse is collecting data from a client who has a herniated intervertebral disc. Which of the following findings
should the nurse expect? (Select all that apply.)
A. Tingling in the arms
B. Low back pain
C. Shoulder pain
D. Hip pain
E. Stiff neck

52. A nurse is collecting data from a client who has systemic lupus erythematosus (SLE). Which of the following
findings should the nurse expect?
A. Thickened skin
B. Spinal deformity
C. Iritis
D. Facial rash
53. A nurse at an urgent care center cares for four clients with leg or foot injuries. Which of the following client reports
should suggest to the nurse that the client has an ankle sprain?
A. Dropping a 10-lb weight on his lower leg at the health club
B. Having ankle pain after running a 10-mile race
C. Twisting his foot while running bases during a baseball game
D. Getting hit by another soccer player on the field
54. A nurse is reinforcing teaching a client who is lactulose intolerant. Which of the following should be included in the
teaching?
A. “You should increase the fiber in your diet.”
B. “You should increase the calories in your diet.”
C. “You should decrease the dairy products in your diet.”
D. “You should decrease the proteins in your diet.”
55. A nurse is caring for a client who reports pleuritic pain on the right side. The nurse notices that the client has
dyspnea, decreased movement of the chest wall, and absent breath sounds on the right side. The nurse should
suspect that the client has which of the following?
A. Pleural effusion
B. Pulmonary embolism
C. Pulmonary infection
D. Empyema

56. A nurse is reinforcing teaching with a client who has emphysema about self-management strategies. Which of the
following client statements indicates that the client understands the instructions?
A. “I will inhale slowly through pursed lips to help me breathe better.”
B. “I will drink a total of 2 quarts of fluid every day.”
C. “I will follow a daily diet high in calories and protein.”
D. “I will lie on my stomach to practice abdominal breathing every day.”
57. A client comes to the emergency department reporting chest pain that is sharp, knife-like, and localized to an area
he points to with one finger. The nurse should document this chest pain as which of the following?
A. Angina pectoris
B. Cardiogenic pain
C. Myocardial infarction
D. Pleuritic pain
58. A school nurse interprets the peak expiratory flow rate for a child with asthma and finds that the child is in the
yellow zone of the client’s asthma action plan. This means which of the following? (Select all that apply.)
A. The child should use his quick-relief inhaler.
B. The child’s asthma is getting worse.
C. The child’s peak flow is 50% to 79% of his best peak flow.
D. The child needs to go to the hospital.
E. The child is able to perform his usual activities.
59. A nurse is talking with a client who is about to start using sublingual nitroglycerin (Nitrostat) to treat angina
pectoris. The client asks the nurse how long he has to take the medication before his condition is cured. The nurse
should first
A. ask the client what he knows about his diagnosis.
B. make sure the client knows how to take his medication.
C. provide the client with written information about angina pectoris.
D. explain that the medication may help control the client’s symptoms.

60. A client who is at 22 weeks of gestation has been unable to control her gestational diabetes with diet and exercise.
The nurse should explain to the client that it is likely that the provider will prescribe which of the following
medications to control her blood glucose levels?
A. Acarbose (Precose)
B. Repaglinide (Prandin)
C. Regular insulin (Humulin R)
D. Glipizide (Glucotrol)
61. A nurse in a family health clinic is collecting data as part of a routine physical examination of a client who is about
to enter high school. The nurse observes an abnormal curvature of the spine. The nurse should expect the
provider to document which of the following disorders?
A. Scoliosis
B. Kyphosis
C. Lordosis
D. Ankylosis
62. A school nurse is completing routine health evaluations for school-aged children. Which of the following should
alert the nurse to the possibility of pediculosis?
A. Patches of baldness
B. Blisters on the scalp
C. Reports of scalp itchiness
D. Dry patches on the scalp
63. A nurse is creating a plan of care for an older client who has a WBC of 2000/uL after three rounds of
chemotherapy. Which of the following actions should the nurse implement?
A. Humidify the client’s room.
B. Serve cooked fruit with meals.
C. Clean dentures in a denture cup.
D. Replace the flowers with fresh water daily.

64. A nurse is creating a dietary plan for an adult female who has a hemoglobin level of 9.8 g/dL. Which of the
following foods will help to improve this result?
A. Carrots
B. Raisins
C. Maple syrup
D. Orange juice
65. A nurse notes a client who has Parkinson disease shows signs of dyskinesia. Which of the following physical
manifestations should the nurse expect?
A. Difficulty swallowing
B. Difficulty speaking
C. Difficulty moving
D. Difficulty breathing
66. A nurse is monitoring a client who has a spinal cord injury and suspects autonomic dysreflexia. Which of the
following actions should the nurse implement first?
A. Check the client for a fecal impaction.
B. Ensure the room temperature is warm.
C. Check the client’s bladder for distention.
D. Place the client in a sitting position.
67. A nurse is collecting data on a client who has meningitis and notes when passively flexing the client’s neck there is
an involuntary flexion of both legs. Which of the following conditions is the client displaying?
A. Kernig’s sign
B. Nuchal rigidity
C. Brudzinski sign
D. Bradykinesia

68. A nursery nurse is admitting a term newborn following a cesarean birth. The nurse observes that the infant’s skin
is slightly yellow. This finding indicates the newborn is experiencing a complication related to which of the
following?
A. Maternal/newborn blood group incompatibility
B. Absence of vitamin K
C. Physiologic jaundice
D. Maternal cocaine abuse
69. A nurse is caring for a client who has a peptic ulcer. Which of the following findings is a risk factor for this
condition?
A. History of bulimia
B. History of corticosteroid use
C. Drinks green tea
D. Has occasional glass of wine
70. A nursing is caring for a client who has Cushing's disease and is reviewing nutrition therapy. Which of the following
dietary modifications should be included in this discussion?
A. Limit potassium rich foods in the diet.
B. Increase protein intake.
C. Increase caloric intake.
D. Decrease fat intake to 5% of total calories.
71. A nurse is assisting in planning care for a client who is being treated for acute phencyclidine (PCP) intoxication.
Which of the following should the nurse suggest for inclusion in the plan of care?
A. Monitor for autonomic hyperactivity.
B. Assess for elevation of vital signs.
C. Implement suicide precautions.
D. Maintain ready access to naloxone. (Narcan)

72. A nurse is reinforcing teaching to a client who has diabetes mellitus. Which of the following statements by the
client indicates an understanding of the manifestations of hypoglycemia?
A. “I will feel shaky.”
B. “I will be more thirsty than usual.”
C. "My skin will be warm and moist."
D. “My appetite will be decreased.”
73. A nurse is caring for a client who has heart failure and is prescribed furosemide (Lasix). For which of the following
findings should the nurse withhold the medication?
A. Weight gain
B. Increased blood pressure
C. Hematocrit of 33.4%
D. Potassium 2.8
74. A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the
following is an appropriate nursing intervention for this client at this time?
A. Elevate the foot of the bed.
B. Encourage sitting up as much as possible.
C. Elevate the stump on a pillow.
D. Have the client lie prone several times a day.
75. A client with a new diagnosis of gout asks the nurse what he can do to decrease his uric acid levels. Which of the
following is an appropriate response?
A. Eat less liver, sardines, and shrimp.
B. Eat more oranges, grapefruit, and lemons.
C. Drink 1 to 1.5 L of fluid each day.
D. Have a glass of red wine with dinner each day.
76. A nurse in an urgent care center is caring for a child who has a forearm fracture. The parent tells the nurse that the

provider said it was a greenstick fracture and asks what that means. The nurse should explain that
A. the bone cracked lengthwise but didn’t break all the way through.
B. fragments of bone have splintered into the surrounding tissue.
C. the bone ends have been forced toward each other.
D. the sharp edge of the bone has broken through the skin.
77. A nurse is caring for a client four days following acute radiation exposure. Which of the following findings indicates
possible damage to the client's WBC?
A. Fever and chills
B. Prolonged bleeding
C. Insomnia
D. Pruritus
78. A nurse is performing pulmonary hygiene for a client who has a respiratory infection. When the client asks how the
position the nurse put him in can help, the nurse should explain that lying on his side with pillows elevating the
right side of his chest helps mobilize secretions from which of the following lung segments?
A. Lateral segment of the left lower lobe
B. Lateral segment of the right lower lobe
C. Posterior segment of the left upper lobe
D. Posterior segment of the right upper lobe
position the nurse put him in can help, the nurse should explain that lying on his back with his head elevated helps
mobilize secretions from which of the following lung segments?
A. Anterior segment of the right upper lobe
B. Anterior segment of the right middle lobe
C. Posterior segment of the right middle lobe
D. Posterior segment of the right lower lobe

position the nurse put him in can help, the nurse should explain that lying on his stomach with his head lower than
his feet helps mobilize secretions from which of the following lung segments?
A. Apical segments
B. Both upper lobes
C. Anterior segments of both lower lobes
D. Posterior segments of both lower lobes
81. A nurse is performing chest physiotherapy for a client with a respiratory infection to help mobilize thick pulmonary
secretions so she can expectorate them. To increase the velocity and turbulence of the air the client exhales, the
nurses should use which of the following techniques?
A. Postural drainage
B. Nebulization
C. Percussion
D. Vibration
82. A nurse who is caring for a newborn observes signs of diaphoresis, jitteriness, and lethargy. Which of the following
is the appropriate nursing action?
A. Obtain blood glucose by heel stick.
B. Initiate phototherapy.
C. Measure the newborn’s blood pressure.
D. Place the newborn in a radiant warmer.
83. A nurse is reinforcing discharge teaching on self-administered peritoneal dialysis with a client. Which of the
following statements by the client indicates a need for further teaching?
A. “The fluid from my abdomen will be clear or slightly yellow.”
B. “The catheter can become infected even with sterile precautions.”
C. “The microwave in my kitchen can warm the solution before using it.”
D. “The volume of the output solution should be greater than the input solution.”

84. A nurse is caring for a client who has a Jackson-Pratt (JP) drain. Which of the following actions should the nurse
implement? (Select all that apply.)
A. Connect drainage tube to wall suction.
B. Secure drainage tube at insertion site with tape.
C. Fasten drainage device to the client’s gown.
D. Report serosanguineous drainage to charge nurse.
E. Empty collection chamber using sterile technique.
85. A nurse is providing teaching to a school-age child who is newly diagnosed with type 1 diabetes mellitus. Which of
the following statements by the child should indicate to the nurse a need for further teaching?
A. “I will test my blood sugar before meals and at bedtime.”
B. “I should eat a snack before playing soccer.”
C. “I should not take my Regular insulin when I am sick.”
D. “I will rotate injections within the abdominal area.”
86. A nurse is caring for a client who is receiving IV fluids to correct dehydration. Which of the following lab values
should indicate to the nurse that the client is effectively responding to treatment?
A. Sodium (Na+) 165 mEq/L
B. Potassium (K+) 3.2 mEq/L
C. Urine specific gravity 1.020
D. Hematocrit (Hct) 62%
87. A nurse is planning care for a client who has thrombocytopenia. Which of the following findings is most appropriate
for the nurse to monitor with this disease process?
A. Malnutrition
B. Fatigue
C. Ecchymosis
D. Fever

88. A nurse is assessing a client who has obstruction of the common bile duct due to cholelithiasis. Which of the
following is an expected finding?
A. Fatty stools
B. Straw-colored urine
C. Tenderness in the left upper abdomen
D. Ecchymosis of the extremities
89. The RN on the unit asks the Student Nurse to go and get her an isotonic IV fluid out of the central supply room on
the unit. The student nurse knows that all of the following IV fluids are isotonic except which one?
A. 5% Dextrose in Water
B. 0.9% NaCl
C. Lactated Ringers Solution
D. 3% NaCl
90. The nurse totals the Intake and Output for the client for the 24-hour period. The total intake was 2400 milliliters
(ml). Based on the total intake, what is the expected Output for that same period of time?
A. 1500 ml
B. 2000 ml
C. 1800 ml
D. 2400 ml
91. Which indicator suggests to the nurse that hypoxemia is occurring?
A. Decreased PaO2
B. Decreased HCO3
C. Decreased pH
D. Decreased PaCO2
92. Which indicator suggests to the nurse that hypoxemia is occurring in the client?

A. Decreased PaO2
B. Decreased HCO3
C. Decreased pH
D. Decreased PaCO2
93. The nurse admits a 2 month old infant to the hospital with a respiratory condition. The baby is coughing up clear
mucous and has a pale skin color. The physician has ordered a cool mist tent and oxygen to run at 2 L. Which
anatomical characteristic of a 2 month old baby does the nurse recognize as contributing to the infant's illness?
A. Small heart
B. Weak muscles
C. Narrow bronchi
D. Immature nervous system
94. The nurse admits a 2 month old infant to the hospital with a respiratory condition. The baby is coughing up clear
mucous and has a pale skin color. The physician has ordered a cool mist tent and oxygen to run at 2 Liters. Which
A. Small heart
B. Weak muscles
C. Narrow bronchi
95. Oxygen is transported by the hemoglobin in red blood cells to the cells of the body. When the nurse assesses the
young adult client's respiratory rate at 28 breaths per minute, heart rate at 130 beats per minute, and oxygen
saturation at 90%, she suspects that the client is developing (or has) which condition?
A. Dyspnea
B. Eupnea
C. Apnea
D. Hypoxia
96. The parents of a 4 month old infant bring the child to the clinic after two days of diarrhea. Which metabolic

regulatory process should be addressed first?
A. Blood glucose homeostasis
B. Fluid and electrolyte balance
C. Normal physiological response to stress.
D. Maintain body energy requirements
97. What is the purpose of the passageways of the kidney in addition to permitting urine to flow to the bladder?
A. Acts as a valve covering the junction between the ureters and the bladder.
B. Surround the Bowman's capsule, which is where the formation of urine begins.
C. Selectively reabsorb or secrete substance to maintain fluids and electrolytes
D. Control external sphincter of the urethra and permit the control of urination
98. A client who was in a motor vehicle accident reported chest pain and difficulty breathing. The chest x-ray reveals a
pneumothorax and arterial blood gases are drawn. Which findings should the nurse expect?
A. pH 7.12; PaO2-89, PaCO2-51, HCO3-24.
B. pH 7.42; PaO2-100, PaCO2-36, HCO3-23
C. pH 7.06; PaO2-98, PaCO2-35, HCO3-20
D. pH 7.51; PaO2 96, PaCO2-38, HCO3-29
99. Which client is at risk for metabolic alkalosis?
A. A client who is experiencing shortness of breath after snow skiing all day.
B. A diebetic client who is in ketoacidosis.
C. An elderly client with pneumonia
D. A client who takes TUMS several times a day for indigestion.
100.A client's arterial blood gas results revealed: pH 7.33, HCO3 20, PaCO2 40, and O2 Sat 95%. Which acid-base
imbalance is present?
A. Metabolic acidosis

B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
101.A nurse is caring for a client who has an exacerbation of gout. When collecting data from the client, which of the
following joint alterations should the nurse expect to observe? (Select all that apply.)
A. Hyperemia
B. Erythema
C. Tophi
D. Decreased mobility
E. Symmetrical joint pain
F. Swollen glands
102.A nurse is assigned to provide care to four clients who have drainage tubes. Which of the following clients should
the nurse recognize is at risk for hypokalemia?
A. A client who has an NG tube to suction
B. A client who has an indwelling urinary catheter to gravity
C. A client who has a chest tube to water seal
D. A client who has a nephrostomy tube to a drainage bag
103.A nurse is obtaining a client's vital signs. The nurse suspects that the client is developing shock based on which
of the following values?
A. BP 180/110 mm Hg, pulse 40/min
B. BP 100/65 mm Hg, pulse 56/min
C. BP 130/80 mm Hg, pulse 110/min
D. BP 80/40 mm Hg, pulse 126/min
104.A nurse is assisting with an admission assessment on a client. Which of the following findings should the nurse
report to the charge nurse as an indicator of dehydration?

A. Red mucous membranes
B. Jugular vein distention
C. Skin tenting present
D. Blood pressure 178/90 mm Hg
105.A nurse is collecting data as part of a neurological assessment for a client who is receiving treatment for head
trauma. Which of the following will give the nurse information about the function of the third cranial nerve?
A. Instruct the client to look up and down without moving his head.
B. Observe the client’s ability to smile and frown.
C. Evaluate the client’s pupillary reaction to light.
D. Ask the client to shrug his shoulders against passive resistance.
106.A nurse is caring for a client following surgical treatment for a brain tumor near the hypothalamus. For which of
the following is the client at risk?
A. Inability to regulate body temperature
B. Bradycardia
C. Visual disturbances
D. Inability to perceive sound
107.A nurse is attending a cardiopulmonary resuscitation (CPR) class. When performing CPR for an infant, the nurse
should evaluate circulation by palpating which of the following pulses?
A. Radial
B. Femoral
C. Carotid
D. Brachial
108.A nurse is reinforcing teaching for a client who has warts on his hands, the nurse should include which of the
following in the teaching?
A. An antibiotic will be prescribed to treat the warts.

B. Warts on the hands are usually not painful.
C. Warts are most common in older adults.
D. A biopsy will be prescribed on all warts rule out malignancy.
109.A nurse in a provider's office is caring for a client who reports pruritus and reddened, fluid-filled vesicles on her
lower leg. The nurse suspects which of the following disorders?
A. Cellulitis
B. Contact dermatitis
C. Folliculitis
D. Seborrheic dermatitis
110.A nurse is reinforcing teaching for a client who has a new diagnosis of atopic dermatitis. Which of the following
statements is appropriate for the nurse to include?
A. "You will need to take the entire prescription of antibiotics even if your symptoms improve."
B. "Your provider may recommend a daily antihistamine to help control your symptoms."
C. "You should thoroughly cleanse your mouth with a prescribed mouthwash after each meal."
D. "Your provider will remove the lesions with liquid nitrogen."
111.A nurse is collecting data on a client’s cardiac functioning and auscultates an S3 sound. The nurse is aware that
this sound represents which of the following?
A. Atrial gallop
B. Ventricular gallop
C. Closure of the aortic valve
D. Closure of pulmonic valve
112.A nurse is caring for a client who is receiving oxygen at 2 L/min via a nasal cannula. What oxygen concentration
is the client receiving?
A. 28%
B. 36%

C. 50%
D. 70%
113.A nurse is caring for a client who is in the early stages of hypoxia and is receiving oxygen therapy. When
collecting data from this client, the nurse should expect to find which of the following early indications of hypoxia?
A. Bradypnea
B. Peripheral edema
C. Cyanosis
D. Hypertension
114.A nurse is collecting data from a client who has respiratory insufficiency. Which of the following findings should
the nurse recognize as an early sign of inadequate oxygenation?
A. Diaphoresis
B. Combativeness
C. Oliguria
D. Restlessness
115.A nurse is assisting with the care of a client who arrives at the emergency department after being injured in a
work-related explosion. The nurse inspects the wound on the client's leg that has torn skin tissue underneath.
The nurse correctly reports this as which of the following types of wounds?
A. Laceration
B. Avulsion
C. Abrasion
D. Puncture
116.A nurse is planning to collect data on a client’s abdomen who reports “stomach pain”. Which of the following
actions should the nurse do first?
A. Auscultate
B. Percuss

C. Inspect
D. Palpate
117.A nurse is caring for a post-operative client at 3:30 AM. The client IV fluids are infusing at 120 mL/hr, how many
mL of IV fluids should infuse by 6 AM?
______ mL
118.A nurse is caring for a client who has a stage 3 pressure ulcer. Which of the following interventions should the
nurse recommend for inclusion in the plan of care?
A. Apply a heat lamp twice a day.
B. Cleanse with saline solution.
C. Cleanse with povidone-iodine solution.
D. Massage reddened areas with dressing changes.
119.The RN on the unit asks the Student Nurse to go and get her an isotonic IV fluid out of the central supply room on
the unit. The student nurse knows that all of the following IV fluids are isotonic except which one?
A. 5% Dextrose in Water
B. 0.9% NaCl
C. Lactated Ringers Solution
D. 3% NaCl
120.The nurse totals the Intake and Output for the client for the 24-hour period. The total intake was 2400 milliliters
(ml). Based on the total intake, what is the expected Output for that same period of time?
A. 1500 ml
B. 2000 ml
C. 1800 ml
D. 2400 ml

121.Which indicator suggests to the nurse that hypoxemia is occurring?
A. Decreased PaO2
B. Decreased HCO3
C. Decreased pH
D. Decreased PaCO2
122.Which indicator suggests to the nurse that hypoxemia is occurring in the client?
A. Decreased PaO2
B. Decreased HCO3
C. Decreased pH
D. Decreased PaCO2
123.The nurse admits a 2 month old infant to the hospital with a respiratory condition. The baby is coughing up clear
mucous and has a pale skin color. The physician has ordered a cool mist tent and oxygen to run at 2 L. Which
A. Small heart
B. Weak muscles
C. Narrow bronchi
124.The nurse admits a 2 month old infant to the hospital with a respiratory condition. The baby is coughing up clear
mucous and has a pale skin color. The physician has ordered a cool mist tent and oxygen to run at 2 Liters.
Which anatomical characteristic of a 2 month old baby does the nurse recognize as contributing to the infant's
illness?
A. Small heart
B. Weak muscles
C. Narrow bronchi

125.Oxygen is transported by the hemoglobin in red blood cells to the cells of the body. When the nurse assesses the
young adult client's respiratory rate at 28 breaths per minute, heart rate at 130 beats per minute, and oxygen
saturation at 90%, she suspects that the client is developing (or has) which condition?
A. Dyspnea
B. Eupnea
C. Apnea
D. Hypoxia
126.The parents of a 4 month old infant bring the child to the clinic after two days of diarrhea. Which metabolic
regulatory process should be addressed first?
A. Blood glucose homeostasis
B. Fluid and electrolyte balance
C. Normal physiological response to stress.
D. Maintain body energy requirements
127.What is the purpose of the passageways of the kidney in addition to permitting urine to flow to the bladder?
A. Acts as a valve covering the junction between the ureters and the bladder.
B. Surround the Bowman's capsule, which is where the formation of urine begins.
C. Selectively reabsorb or secrete substance to maintain fluids and electrolytes
D. Control external sphincter of the urethra and permit the control of urination
128.A client who was in a motor vehicle accident reported chest pain and difficulty breathing. The chest x-ray reveals
a pneumothorax and arterial blood gases are drawn. Which findings should the nurse expect?
A. pH 7.12; PaO2-89, PaCO2-51, HCO3-24.
B. pH 7.42; PaO2-100, PaCO2-36, HCO3-23
C. pH 7.06; PaO2-98, PaCO2-35, HCO3-20
D. pH 7.51; PaO2 96, PaCO2-38, HCO3-29
129.Which client is at risk for metabolic alkalosis?

A. A client who is experiencing shortness of breath after snow skiing all day.
B. A diebetic client who is in ketoacidosis.
C. An elderly client with pneumonia
D. A client who takes TUMS several times a day for indigestion.
130.A client's arterial blood gas results revealed: pH 7.33, HCO3 20, PaCO2 40, and O2 Sat 95%. Which acid-base
imbalance is present?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis

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A. decreased color perception.

B. loss of peripheral vision.

C. bright flashes of light and floaters.

D. eyestrain and headache.

B. "Maybe the behavior is age-related."

Created on:07/17/2018 Page 1

A. Provide only pureed and solid foods.

B. Have a family member feed the client.

C. Add thickener to fluids to increase their consistency.

A. "I will avoid crossing my legs at the knees."

B. "I will use a thermometer to check the temperature of my bath water."

C. "I will wear shoes instead of sandals."

D. "I will wear stockings with elastic tops."

A. Recollapse the reservoir immediately after emptying it.

B. Empty the reservoir when it becomes full.

Created on:07/17/2018 Page 2

Answers cannot be displayed for this alternate item format.

A. Walk with leg braces and crutches.

B. Drive an electric wheelchair with a hand-control device.

C. Drive an electric wheelchair equipped with a chin-control device.

D. Propel a wheelchair equipped with knobs on the wheels.

Created on:07/17/2018 Page 3

A. Recommend a complete vaginal examination.

B. Feel for a full bladder.

C. Measure the client's vital signs.

D. Check the client's fundus.

E. Symmetrical joint pain

A. A client who has an NG tube to suction

B. A client who has an indwelling urinary catheter to gravity

C. A client who has a chest tube to water seal

D. A client who has a nephrostomy tube to a drainage bag

Created on:07/17/2018 Page 4

A. Combing her hair

B. Eating her breakfast

C. Buttoning her blouse

D. Brushing her teeth

A. Copious serosanguineous drainage from the wound

B. Swelling and tenderness around the wound

C. Maculopapular rash and itching around the wound

D. Brownish-green crusting over the wound

Created on:07/17/2018 Page 5

A. Gestational age of the fetus

B. Location of the fetus and placenta

C. Amount of amniotic fluid

D. Degree of fetal lung maturity

A. Restricting visitors to family members only

B. Avoiding venipunctures whenever possible

C. Limiting oral fluid intake to between meals

D. Prohibiting fresh flowers in the client’s room

A. Scaling patches that are clear in the center.

B. Honey-colored crusts caused by dried exudate.

C. Firm papules with a roughened, finely papillomatous texture.

D. Lines of small blisters surrounding one large blister.

Created on:07/17/2018 Page 6

B. Bile colored vomit

C. Absent bowel sounds

D. Indifferent approach to feedings

A. 120 mL unsweetened fruit juice

D. 240 mL regular soda

B. Poor fluid intake

B. Count the respiratory rate.

D. Prepare equipment for intubation.