PRACTICE TEST

NCLEX-Suddarts
Compiled by Zudota

1. The nurse is reinforcing information to the mother of a child about a synthetic cast
that has been applied to the child for the treatment of a clubfoot. Which of the
following information will the nurse provide to the mother?
A. The cast takes 24 hours to dry.
B. The cast is heavier than a plaster cast.
C. The cast is stronger than a plaster cast.
D. The cast allows for greater mobility than a plaster cast.

Answer: D Rationale: Synthetic casts dry quickly (in less than 30 minutes) and are
lighter than plaster casts. Synthetic casts allow for greater mobility than a plaster
cast. However, synthetic casts are not as strong as plaster casts and are more
expensive.

2. Corticream is prescribed by the physician for a child with atopic dermatitis (eczema)
and the nurse instructs the mother how to apply the cream. The nurse tells the
mother to:
A. Avoid cleansing the area before applying the cream
B. Apply the cream over the entire body
C. Apply a thin layer of cream and rub into the area thoroughly
D. Apply a thick layer of cream in affected areas only

Answer: C Rationale: Corticream is a topical corticosteroid. It should be applied

sparingly and rubbed into the area thoroughly. The affected area should be cleansed
gently before application. It should not be applied over extensive areas. Systemic
absorption is more likely to occur with extensive application.

3. A nurse assists in providing an instructional session to parents regarding impetigo.

Which statement by a parent indicates a need for further instruction?
A. “It is most common in humid weather.”
B. “It begins in an area of broken skin, such as an insect bite.”
C. “It is extremely contagious.”
D. “Lesions are most often located on the arms and chest.”

Answer: D.Rationale: Impetigo is most common during hot, humid summer

months. It begins in an area of  broken skin, such as an insect bite. It may be
caused by Staphylococcus aureus group A beta-hemolytic streptococci, or a
combination of these bacteria. It is extremely contagious. Lesions are usually located
around the mouth and nose, but may be present on the extremities.
4. A nurse provides instructions regarding the use of permethrin 1% (Nix) to the
parents of achild diagnosed with pediculosis (head lice). Which statement by a
parent indicates a need for further instruction?
A. “The medication can be obtained over the counter in a local pharmacy.
B. “The medication is applied to the hair after shampooing and left on for 24 hours.”
C. “The medication is applied to the hair after shampooing, left on for 10 minutes,
and then rinsed out.”
D. “The hair should not be shampooed for 24 hours following treatment.”

Answer: B Rationale: Permethrin 1% is an over-the-counter antilice product that

kills both lice and eggs with one application and has residual activity for 10 days. It
is applied to the hair after shampooing and left for 10 minutes before rinsing out.
The hair should not be shampooed for 24hours after the treatment.

5. A nurse prepares a list of home care instructions for the parents of school children
diagnosedwith pediculosis (head lice). Which of the following is included in the list?
A. Use antilice sprays on all bedding and furniture
B. Take all bedding and linens to the cleaners to be dry cleaned
C. Boil combs and brushes in hot water for 2 hours
D. Vacuum floors, play areas, and furniture to remove any hairs that might carry li ve
nits

Answer: D Rationale: Antilice sprays are unnecessary. Additionally, they should

never be used on a child. Bedding and linens should be washed with hot water and
dried on a hot setting. Items that cannot be washed should be dry cleaned or sealed
in plastic bags in a warm place for C weeks. Combs and brushes should be boiled or
soaked in antilice shampoo or hot water for 15 minutes. Thorough home cleaning is
necessary to remove any remaining lice or nits.

6. A pediatric nursing instructor ask a nursing student to describe the cause of the
clinical manifestations that occur Which of the following is the correct response by
the nursing student?
A. “Sickled cells increase the blood flow through the body and cause a great deal of
pain.”
B. “The sickled cells mix with the sickled cells and cause the immune system to
becomedepressed.”
C. “Bone marrow depression occurs because of the development of sickled cells.”
D. “Sickled cells are unable to flow easily through the microvasculature and their
clumping obstructs blood flow.”

Answer: D Rationale: All the clinical manifestations of sickle cell disease are a result
of the sickled cells being unable to flow easily through the microvasculature, and
 their clumping obstructs bloodflow. With reoxygenation, most of the sickled red
blood cells resume their normal shape.Options 1, 2, and 3 are inaccurate.Test-
A nurse instructs the mother of a child with sickle cell disease regarding the
precipitating factors related to pain crisis. Which of the following, if identified by the
mother as a precipitating factor, indicates the need for further instructions?
A. Infection
B. Trauma
3. Fluid overload
D. Stress

Answer: C Rationale: Pain crisis may be precipitated by infection, dehydration,

hypoxia, trauma, or generalstress. The mother of a child with sickle cell disease
should encourage fluid intake of 1.5 to 2times the daily requirement to prevent
dehydration.

7. A nurse caring for a child with aplastic anemia reviews the laboratory results and
notes a white blood cell (WBC) count of 6000/ µ L and a platelet count of
27,000/mm3Which nursing intervention will the nurse suggest to incorporate into
the plan of care?
A. Maintain strict isolation precautions
B. Encourage naps
C. Encourage a diet high in iron
D. Encourage quiet play activities

Answer: D Rationale: Precautionary measures to prevent bleeding should be taken

when a child has a low platelet count. These include no injections, no rectal
temperatures, use of a soft toothbrush, and abstinence from contact sports or
activities that could cause an injury. Strict isolation would be required if the WBC
count were low. Options 2 and 3 are unrelated to the risk of bleeding.

8. A nurse reinforces instructions regarding home care to the parents of a 3-year-old

child hospitalized with hemophilia. Which statement by a parent indicates a need for
further instructions?
A. “I will supervise my child closely.”
B. “I will pad corners of the furniture.”
C. “I will remove household items that can easily fall over.”
D. “I will avoid immunizations being administered and dental hygiene treatments for
my child.”

Answer: D Rationale: The nurse needs to stress the importance of immunizations,

dental hygiene, and routine well-child care. Options 1, 2, and 3 are appropriate
statements. The parents are also provided instructions regarding measures to take in
the event of blunt trauma, especially trauma involving the joints, and are instructed
to apply prolonged pressure to superficial wounds until the bleeding has stopped.
9. A nurse is reinforcing home care instructions to the mother of a 10-year-old child
with hemophilia. Which activity would the nurse suggest that the child could safely
participate in with peers?
A. Basketball
B. Swimming
C. Soccer 
D. Field hockey

Answer: B Rationale: Children with hemophilia need to avoid contact sports and
need to take precautions,such as wearing elbow and knee pads and helmets, when
participating in other sports. The safest activity that will prevent injury is swimming.
Test-Taking Strategy: Note the key word, safely. Recalling that bleeding is a major
concern in this condition will assist in directing you to option 2. Also, note that the
activities in options 1, 3,and 4 present the potential for injury.

10. A nurse collects data on a client with a diagnosis of bipolar affective disorder–
mania. Thefinding that requires the nurse’s immediate intervention is:
A. The client’s outlandish behaviors and inappropriate dress
B. The client’s grandiose delusions of being a royal descendant of King Arthur 
C. The client’s nonstop physical activity and poor nutritional intake
D. The client’s constant, incessant talking that includes sexual innuendoes and
teasing the staff 

Answer: C Rationale: Mania is a mood characterized by excitement, euphoria,

hyperactivity, excessive energy, decreased need for sleep, and impaired ability to
concentrate or complete a single train of thought. It is a period when the mood is
predominantly elevated, expansive, or irritable. Option C identifies a physiological
need requiring immediate intervention.

11. A client in a manic state emerges from her room. She is topless and is making sexual
remarks and gestures toward staff and peers. The appropriate nursing action is to:

A. Quietly approach the client, escort her to her room, and assist her in getting
dressed.
B. Approach the client in the hallway and insist that she go to her room.
C. Confront the client on the inappropriateness of her behaviors and offer her a
time-out.
D. Ask the other clients to ignore her behavior; eventually she will return to her
room.

Answer: A Rationale: A person who is experiencing mania lacks insight and

judgment, has poor impulse control, and is highly excitable. The nurse must take
control without creating increased stress or anxiety to the client. A quiet, firm
approach while distracting the client (walking her to her room and assisting her to
get dressed) achieves the goal of having her being dressed appropriately
and preserving her psychosocial integrity. Option D is inappropriate. “Insisting” that
 the client go to her room may meet with a great deal of resistance. Confronting the
client and offering her a consequence of “time-out” may be meaningless to her

12. A nurse reviews the activity schedule for the day and determines that the best
activity that the manic client could participate in is:

A. A brown bag lunch and a book review

B. Ping-Pong
C. A paint by number activity
D. A deep breathing and progressive relaxation group

Answer: B Rationale: A person who is experiencing mania is overactive, full of

energy, lacks concentration ,and has poor impulse control. The client needs an
activity that will allow him or her to utilize excess energy, but not endanger others
during the process. Options A, C, and D are relatively sedate activities that require
concentration, a quality that is lacking in the manic state. Such activities may lead to
increased frustration and anxiety for the client. Ping-Pong is an activity that will help
to expend the increased energy this client is experience

13. A client who is delusional says to the nurse, “The federal guards were sent to kill
me.” The nurse should make which appropriate response to the client?
A. “The guards are not out to kill you.”
B. “I don’t believe this is true.”
C. “I don’t know anything about the guards. Do you feel afraid that people are trying
to hurt you?”
D. “What makes you think the guards were sent to hurt you?”

Answer: C Rationale: Disagreeing with delusions may make the client more
defensive and the client may cling to the delusions even more. It is most therapeutic
for the nurse to empathize with the client’s experience. Options A and B are
statements that disagree with the client. Option D encourages discussion regarding
the delusion

14. A woman comes into the emergency room in a severe state of anxiety following a
car accident. The most important nursing intervention is to:

A. Remain with the client

B. Put the client in a quiet room
C. Teach the client deep breathing
D. Encourage the client to talk about her feelings and concerns

Answer: A Rationale: If a client is left alone with severe anxiety, he or she may feel
abandoned and become overwhelmed. Placing the client in a quiet room is also
indicated, but the nurse must stay with the client. It is not possible to teach the
 client deep breathing until the anxiety decreases. Encouraging the client to discuss
concerns and feelings would not take place until the anxiety has decreased.

15. A male client with delirium becomes agitated and confused in his room at night. The
best initial intervention by the nurse is to:
A. Use a night-light and turn off the television.
B. Keep the television and a soft light on during the night.
C. Move the client next to the nurse’s station.
D. Play soft music during the night and maintain a well-lit room

Answer: A Rationale: It is important to provide a consistent daily routine and a low-

stimulation environment when the client is agitated and confused. Noise levels
including a radio and television may add to the confusion and disorientation. Moving
the client next to the nurses’ station is not the initial intervention.

16. A nurse is collecting data on a client who is actively hallucinating. Which nursing
statement would be therapeutic at this time?
A. "I talked to the voices you're hearing and they won't hurt you now."
B. "I can hear the voice and she wants you to come to dinner."
C. "Sometimes people hear things or voices others can't hear."
D. "I know you feel ‘they are out to get you’ but it's not true."

Answer: C Rationale: It is important for the nurse to reinforce reality with the
client. Options A, B, and D donot reinforce reality but reinforce the hallucination that
the voices are real.Test-Taking Strategy: Use the process of elimination. Note that
options A, B, and D all indicatereinforcement to the client that the voices are real.
Option C is the only statement that indicates reality.

17. A nurse is caring for a client with a diagnosis of depression. The nurse monitors for
signs of constipation and urinary retention, knowing that these problems are most
likely caused by:

A. Inadequate dietary intake and dehydration

B. Lack of exercise and poor diet
C. Poor dietary choices
D. Psychomotor retardation and side effects of medication

Answer: D Rationale: Constipation can be related to inadequate food intake, lack of

exercise, and poor diet.In this situation, urinary retention is most likely due to
medications. Option D is the only optionthat addresses both constipation and urinary
retention.

18. A client is admitted to the inpatient unit and is being considered for electroconvulsive
therapy (ECT). The client appears calm, but the family is hypervigilant and anxious.
 The client’s mother   begins to cry and states, “My son’s brain will be destroyed.
How can the doctor do this to him?”The nurse makes which therapeutic response?

A. “It sounds as though you need to speak to the psychiatrist.”

B. “Your son has decided to have this treatment. You should be supportive of him.”
C. “Perhaps you’d like to see the ECT room and speak to the staff.”
D. “It sounds as though you have some concerns about the ECT procedure. Why
don’t we sit down together and discuss any concerns you may have.”

Answer: D Rationale: The nurse needs to encourage the family and client to
verbalize their fears andconcerns. Option D is the only option that encourages
verbalization. Options A, B, and C avoiddealing with the client or family concerns

2O. A nurse is caring for a client who has been treated with long-term antipsychotic
medication. As part of the nursing care plan, the nurse monitors for tardive dyskinesia.
In the event that tardive dyskinesia occurs, the nurse would most likely observe:

A. Abnormal movements and involuntary movements of the mouth, tongue, and

face
B. Abnormal breathing through the nostrils
C. Severe headache, flushing, tremor, and ataxia
D. Severe hypertension, migraine headache, and ‘marbles in the mouth’ syndrome

Answer: A Rationale: Tardive dyskinesia is a severe reaction associated with the

long-term use of antipsychotic medication. The clinical manifestations are abnormal
movements (dyskinesia) and involuntary movements of the mouth, tongue, and
face. In its more severe form, tardive dyskinesia involves the fingers, arms, trunk,
and respiratory muscles. When this occurs, the medication is discontinued.

19. A client who is diagnosed with pedophilia and has been recently paroled as a sex
offender says, "I'm in treatment and I have served my time. Now this group has
posters of me all over the neighborhood telling about me with my picture on it."
Which of the following is an appropriate response by the nurse?

A."You understand that people fear for their children but you're feeling unfairly
treated?
B. "When children are hurt as you hurt them, people want you isolated."
C. "You seem angry but you have committed serious crimes against several children,
so your neighbors are frightened."
D. "You're lucky it doesn't escalate into something pretty scary after your crime

Answer: A Rationale: Focusing and verbalizing the implied is the therapeutic

response because it assists the client to clarify thinking and re-examine what the
client is really saying. Option A is the only option that reflects the use of this
therapeutic communication technique. Option B is insensitive and anxiety-provoking.
 Option C does not facilitate the client’s expression of feelings. Option D gives advice
and also does not facilitate the client's expression of feelings.

20. A nurse is preparing for the hospital discharge of a client with a history of command
hallucinations to harm self or others. The nurse instructs the client about
interventions for hallucinations and anxiety and determines that the client
understands the interventions when the client states:

A. "My medications won’t make me anxious."

B. "I can call my therapist when I'm hallucinating so that I can talk about my
feelings and plans and not hurt anyone."
C. “I’ll go to support group and talk so that I won't hurt anyone."
D. “I won't get anxious or hear things if I get enough sleep and eat well."

Answer B. Rationale: There may be an increased risk for impulsive and/or aggressive
behavior if a client is receiving command hallucinations to harm (self) or others.
Talking about the auditory hallucinations can interfere with the subvocal muscular
activity associated with a hallucination. Option B is a specific agreement to seek help
and evidences self-responsible commitment and control over his or her own behavior

21. A nurse observes that a client is psychotic, pacing, agitated, and making aggressive
gestures. The client’s speech pattern is rapid and the client’s affect is belligerent.
Based on these observations, the nurse’s immediate priority of care is to:

A. Provide safety for the client and other clients on the unit
B. Offer the client a less stimulated area to calm down and gain control
C. Provide the clients on the unit with a sense of comfort and safety
D .Assist the staff in caring for the client in a controlled environment

Answer: A Rationale: Safety to the client and other clients is the priority. Option A
is the only option that addresses the client and other clients’ safety needs. Option B
addresses the client’s needs. Option C addresses other clients’ needs. Option D is
not client-centered.

22. A client is unwilling to go out of the house for fear of “doing something crazy in
public.”Because of this fear, the client remains homebound except when
accompanied outside by the spouse. The nurse determines that the client has:

A. Social phobia
B. Agoraphobia
C. Claustrophobia
D. Hypochondriasis.
 Answer: B Rationale: Agoraphobia is a fear of being alone in open or public places
where escape might be difficult. Agoraphobia includes experiencing fear or a sense
of helplessness or embarrassment if a phobic attack occurs. Avoidance of such
situations usually results in the reduction of social and professional interactions.
Social phobia focuses more on specific situations, such as the fear of speaking,
performing, or eating in public. Claustrophobia is a fear of closed-in places. Clients
with hypochondriacal symptoms focus their anxiety on physical complaints and are
preoccupied with their health

23. A client has reported that crying spells have been a major problem over the past
several weeks, and that the doctor said that depression is probably the reason. The
nurse observes that the client is sitting slumped in the chair and the clothes that the
client is wearing don’t fit well. The nurse interprets that further data collection
should focus on:

A. Sleep patterns
B. Onset of the crying spells
C. Weight loss
D. Medication compliance

Answer: C Rationale: All the options are possible issues to address; however, the
weight loss is the first item that needs further data collection because ill-fitting
clothing could indicate a problem with nutrition. The client has already told the nurse
that the crying spells have been a problem. Medication or sleep patterns are not
mentioned or addressed in the question.

24. A client was admitted to a medical unit with acute blindness. Many tests are
performed and there seems to be no organic reason why this client cannot see. The
nurse later learns that the client became blind after witnessing a hit-and-run car
accident, in which a family of three was killed. The nurse suspects that the client
may be experiencing a:
A.Psychosis
B. Conversion disorder 
C. Dissociative disorder 
D. Repression

Answer: B Rationale: A conversion disorder is the alteration or loss of a physical

function that cannot be explained by any known pathophysiological mechanism. It is
thought to be an expression of a psychological need or conflict. In this situation, the
client witnessed an accident that was so psychologically painful that the client
became blind. A dissociative disorder is a disturbance or alteration in the normally
integrative functions of identity, memory, or consciousness. Psychosisis a state in
which a person’s mental capacity to recognize reality, communicate, and relate to
 others is impaired, thus interfering with the person’s capacity to deal with life’ s
demands. Repression is a coping mechanism in which unacceptable feelings are kept
out of awareness.

25. A manic client announces to everyone in the dayroom that a stripper is coming to
perform that evening. When the psychiatric aide firmly states that this will not
happen, the manic client becomes verbally abusive and threatens physical violence
to the aide. Based on the analysis of this situation, the nurse determines that the
most appropriate action would be to:

A. Escort the manic client to his or her room, with assistance, and administer PRN
haloperidol(Haldol).
B. Tell the client that smoking privileges are revoked for 24 hours.
C. Orient the client to time, person, and place.
D. Tell the client that the behavior is not appropriate

Answer: A Rationale: The client is at risk for injury to self and others and therefore
should be escorted out of the dayroom. Hyperactive and agitated behavior usually
responds to haloperidol (Haldol) Option 2 may increase the agitation that already
exists in this client. Orientation will not halt the behavior. Telling the client that the
behavior is not appropriate has already been attempted by the psychiatric aide.

26. A nurse notes documentation in a client’s record that the client is experiencing
delusions of persecution. The nurse understands that these types of delusions are
characteristic of which of the following?

A. The false belief that one is a very powerful person

B. The false belief that one is a very important person
C. The false belief that one’s partner is going out with other people
D. The false belief that one is being singled out for harm by others

Answer: D Rationale: A delusion is a false belief held to be true even when there is
evidence to the contrary. A delusion of persecution is the thought that one is being
singled out for harm by others. A delusion of grandeur is the false belief that he or
she is a very powerful and important person. A delusion of jealousy is the false belief
that one’s partner is going out with other people.

27. A child suspected of having sickle cell disease (SCD) is seen in a clinic, and
laboratory studies are performed. A nurse checks the laboratory results, knowing
that which of the following would be increased in this disease?
 A. Platelet count
B. Hematocrit level
C. Reticulocyte count
D. Hemoglobin level

Answer: C Rationale: A diagnosis is established on the basis of a complete blood count,

examination for sickled red blood cells (RBCs) in the peripheral smear, and hemoglobin
electrophoresis. Laboratory studies will show decreased hemoglobin and hematocrit
levels and a decreased platelet count, an increased reticulocyte count, and the presence
of nucleated red blood cells. Increased reticulocyte counts occur in children with SCD
because the life span of their sickledRBCs is shortened.

29. A nurse instructs the mother of a child with sickle cell disease regarding the
precipitating factors related to pain crisis. Which of the following, if identified by the
mother as a precipitating factor, indicates the need for further instructions?

A.Infection
B.Trauma
C. Fluid overload
D .Stress

Answer: C Rationale: Pain crisis may be precipitated by infection, dehydration, hypoxia,

trauma, or general stress. The mother of a child with sickle cell disease should
encourage fluid intake of 1.5 to 2times the daily requirement to prevent dehydration.

28. Oral iron supplements are prescribed for the 6-year-old child with iron deficiency
anemia.The nurse instructs the mother to administer the iron with which best food
item?

A. Water
 B. Milk 
C. Apple juice
D. Orange juice

Answer: D Rationale: Vitamin C increases the absorption of iron by the body. The
mother should beinstructed to administer the medication with a citrus fruit or juice
high in vitamin C.Test-Taking Strategy: Use the process of elimination. Recalling that
vitamin C increases theabsorption of iron will assist in eliminating options 1 and 2.
From the remaining options, selectoption D because this food item contains the
highest amount of vitamin C.

3O.A nurse reinforces instructions regarding home care to the parents of a 3-year
oldbchildhospitalized with hemophilia. Which statement by a parent indicates a need for
further instructions?
A. “I will supervise my child closely.”
B. “I will pad corners of the furniture.”
C. “I will remove household items that can easily fall over.”
D. “I will avoid immunizations being administered and dental hygiene treatments for my
child.”

Answer: D Rationale: The nurse needs to stress the importance of immunizations,

dental hygiene, androutine well-child care. Options 1, 2, and 3 are appropriate
statements. The parents are also provided instructions regarding measures to take in
the event of blunt trauma, especially traumainvolving the joints, and are instructed to
apply prolonged pressure to superficial wounds untilthe bleeding has stopped

31. A nurse has administered a dose of diazepam (Valium) to the client. The nurse
would takewhich most important action before leaving the client’s room?

A. Drawing the shades or blinds closed

B. Putting up the side rails on the bed
C. Giving the client a bedpan
D. Turning down the volume on the television

Answer: B Rationale: Diazepam is a sedative-hypnotic with anticonvulsant and skeletal

muscle relaxant properties. The nurse should institute safety measures before leaving
the client’s room to ensurethat the client does not injure herself or himself. The most
frequent side effects of thismedication are dizziness, drowsiness, and lethargy. For this
reason, the nurse puts the side railsup on the bed before leaving the room to prevent
falls. Options A, C and D may be helpfulmeasures that provide a comfortable, restful
environment. However, option 2 is the one that provides for the client’s safety needs.

32. A nurse provides medication instructions to a client who is taking lithium

carbonate(Eskalith). The nurse determines that the client needs additional instructions if
the client statesthat he or she will:

A. Must monitor lithium blood levels very closely

B. Contact the physician if excessive diarrhea, vomiting, or diaphoresis occurs
C. Take the lithium with meals
D. Decrease fluid intake while taking the lithium

Answer: D Rationale: Because therapeutic and toxic dosage ranges are so close,
lithium blood levels must be monitored very closely, more frequently at first and then
once every several months. Theclient should be instructed to contact the physician if
excessive diarrhea, vomiting, or diaphoresisoccurs. Lithium is irritating to the gastric
mucosa; therefore, lithium should be taken with meals.A normal diet and normal salt
and fluid intake (1500 to 3000 mL/day) should be maintained, because lithium
decreases sodium reabsorption by the renal tubules, which could cause
sodiumdepletion. A low sodium intake causes a relatively increase in lithium retention
amd could lead to toxicity.

33. A client with a psychotic disorder is being treated with haloperidol (Haldol). Which of
the following would indicate the presence of a toxic effect of this medication?

A. Hypotension
B. Nausea
C. Excessive salivation
D. Blurred vision.

Answer: C Rationale: Toxic effects include extrapyramidal symptoms noted as marked

drowsiness andlethargy, excessive salivation, and a fixed stare. Akathisia, acute
dystonias, and tardivedyskinesia are also signs of toxicity. Hypotension, nausea, and
blurred vision are occasional side effects

34. A nurse is caring for a hospitalized client who has been taking clozapine (Clozaril) for
the treatment of a schizophrenic disorder. Which laboratory study prescribed for the
client will thenurse specifically review to monitor for an adverse effect associated with
the use of thismedication?

A. White blood cell count

B. Platelet count
C. Cholesterol level
D. Blood urea nitrogen level.

Answer A. Rationale: Hematological reactions can occur in the client taking clozapine
and includeagranulocytosis and mild leukopenia. The white blood cell count should be
checked beforeinitiating treatment and should be monitored closely during the use of
this medication. Theclient should also be monitored for signs indicating agranulocytosis,
which may include sorethroat, malaise, and fever. Options 2, 3, and 4 are unrelated to
this medication.

35. Neuroleptic malignant syndrome is suspected in a client who is taking

chlorpromazine(Thorazine). Which medication would the nurse prepare in anticipation of
being ordered to treatthis adverse effect related to the use of chlorpromazine?
A. Phytonadione (vitamin K)
B. Bromocriptine (Parlodel)
C. Enalapril maleate (Vasotec)
D. Protamine sulfate

Answer: B Rationale: Bromocriptine is an antiparkinsonian prolactin inhibitor used in

the treatment of neuroleptic malignant syndrome. Vitamin K is the antidote for warfarin
(Coumadin) overdose.Protamine sulfate is the antidote for heparin overdose. Enalapril
maleate is an antihypertensiveused in the treatment of hypertension.

36. Disulfiram (Antabuse) is prescribed for a client who is seen in the psychiatric health
careclinic. The nurse is collecting data on the client and is providing instructions
regarding the useof this medication. Which is most important for the nurse to determine
before administration of this medication?

A. When the last alcoholic drink was consumed

B. A history of diabetes insipidus
C. A history of hyperthyroidism
D. When the last full meal was consumed

Answer: A Rationale: Disulfiram is used as an adjunct treatment for selective clients

with chronicalcoholism who want to remain in a state of enforced sobriety. Clients must
obtain from alcoholintake for at least 12 hours before the initial dose of the medication
is administered. The mostimportant data is to determine when the last alcoholic drink
was consumed. The medication isused with caution in clients with diabetes mellitus,
hypothyroidism, epilepsy, cerebral damage,nephritis, and hepatic disease. It is also
contraindicated in severe heart disease, psychosis, or hypersensitivity related to the
medication.

37. A client receiving lithium carbonate (Eskalith) complains of loose, watery stools
anddifficulty walking. The nurse would expect the serum lithium level to be which of
thefollowing?

A.1. 0.7 mEq/L

B. 1.0 mEq/L
C. 1.2 mEq/L
D. 1.7 mEq/L

Answer: D Rationale: The therapeutic serum level of lithium ranges from 0.6 to 1.2
mEq/L. Serum lithiumlevels above the therapeutic level will produce signs of
toxicity.Test-Taking Strategy: Focus on the data in the question, noting that the client is
experiencingloose, watery stools and difficulty waking. Recalling the therapeutic serum
level of lithium willdirect you to option D. Option D is the only serum level that is not
within the therapeutic ran

38. Fluoxetine hydrochloride (Prozac) is prescribed for the client. The nurse
providesinstructions to the client regarding the administration of the medication. Which
statement by theclient indicates an understanding about administration of the
medication?

A. “I should take the medication right before bedtime with a snack.”

 B. “I should take the medication with my evening meal.”
C. “I should take the medication at noon with an antacid.”
D. “I should take the medication in the morning when I first arise”

Answer: D Rationale: Fluoxetine hydrochloride is administered in the early morning.

39. A client receiving thioridazine (Mellaril) complains that he feels very "faint" when he
tries to get out of bed in the morning. The nurse recognizes this complaint as a
symptom of:

A. Psychosomatic symptoms
B. Cardiac dysrhythmias
C. Respiratory insufficiency.
D.Postural hypotension

Answer: D Rationale: Thioridazine can cause postural hypotension. The client needs to
be taught to get out of bed slowly and to rise from a sitting position slowly because of
this adverse effect related to the medication. Options A, B, and C are unrelated t o the
use of this medication consideration to meals. Options A, B, and C are incorrect.

4O.A client receiving a tricyclic antidepressant arrives at the mental health clinic. Which
observation indicates that the client is correctly following the medication plan?

A. Reports sleeping 12 hours per night and 3 to 4 hours during the day
B. Arrives at the clinic neat and appropriate in appearance
C. Reports not going to work for this past week 
D. Complains of not being able to "do anything" anymore

Answer: B Rationale: Depressed individuals will sleep for long periods, are not able to go
to work, and feel as if they cannot "do anything." Once they have had some therapeutic
effect from their medication, they will report resolution of many of these complaints as
well as demonstrate an improvement in their appearance.

41. A nurse is performing a follow-up teaching session with a client discharged 1 month
ago who is taking fluoxetine (Prozac). What information would be important for the nurse
to gather regarding the adverse effects related to the medication?

A. Problems with excessive sweating

B. Gastrointestinal dysfunctions
C. Cardiovascular symptoms
D. Problems with mouth dryness
Answer: B Rationale: The most common adverse effects related to fluoxetine include
central nervous system (CNS) and gastrointestinal (GI) system dysfunction. This
medication affects the GI system by causing nausea and vomiting, cramping, and
diarrhea. Options A, C, and D are not adverse effects of this medication

42. A client is placed on chloral hydrate (Noctec) for short-term treatment. Which nursing
action indicates an understanding of the major side effect of this medication?

A. Monitoring neurological signs every 2 hours

B. Monitoring the blood pressure every 4 hours
C. Instructing the client to call for ambulation assistance
D. Lowering the bed and clearing a path to the bathroom at bedtime

Answer: C Rationale: Chloral hydrate causes sedation and impairment of motor

coordination; therefore, safety measures need to be implemented. The client is instructed
to call for assistance with ambulation. Options A and B are not specifically associated with
the use of this medication. Although option D is an appropriate nursing intervention, it is
most important to instruct the client to call for assistance with ambulation.

43. A client admitted to the hospital gives the nurse a bottle of clomipramine (Anafranil).
The nurse notes that the medication has not been taken by the client in 2 months. What
behaviors observed in the client would validate noncompliance with this medication?

A. Frequent hand washing with hot, soapy water 

B. Complaints of hunger 
C. A pulse rate below 60 beats per minute
D. Complaints of insomnia

Answer: A Rationale: Clomipramine is commonly used in the treatment of obsessive-

compulsive disorder. Hand washing is a common obsessive-compulsive behavior. Weight
gain is a common side effect of this medication. Tachycardia and sedation are side
effects. Insomnia may occur as a seldom side effect.

44. A client in the mental health unit is administered haloperidol (Haldol) intramuscularly .
The nurse would check which of the following to determine medication effectiveness?

A. The client’s vital signs

B. The physical safety of other unit clients
C. The client’s nutritional intake
D. The client’s orientation and delusional status
Answer: D Rationale: Haloperidol is used to treat clients exhibiting psychotic features.
Therefore, to determine medication effectiveness, the nurse would check the client’s
orientation and delusional status. Vital signs are routine and not specific to this situation.
The physical safety of other clients is not a direct assessment of this client. Monitoring
nutritional intake is not related to this situation.

45. A client arrives at the health care clinic and tells the nurse that he has been doubling
his daily dosage of bupropion (Wellbutrin) to help him get better faster. The nurse
understands that the client is now at risk for which of the following?

A. Orthostatic hypotension
B. Seizure activity
C. Weight gain
D. Insomnia

Answer: B Rationale: Bupropion does not cause significant orthostatic blood pressure
changes. Seizure activity is common in dosages greater than 450 mg daily. Bupropion
frequently causes a drop in body weight. Insomnia is a side effect but seizure activity
causes a greater client risk

46. A nurse is caring for a female client who was recently admitted to the hospital for
anorexia nervosa. The nurse enters the client’s room and notes that the client is doing
rigorous push-ups. Which nursing action is appropriate?
A. Allow the client to complete her exercise program.
B. Tell the client that she is not allowed to exercise rigorously.
C. Interrupt the client and offer to take her for a walk.
D. Interrupt the client and weigh her immediately.

Answer: C Rationale: Clients with anorexia nervosa are frequently preoccupied with
rigorous exercise and push themselves beyond normal limits to work off caloric intake.
The nurse must provide for appropriate exercise as well as place limits on rigorous
activities. Options A, B, and D are inappropriate nursing actions.

47. A nurse is caring for a client with anorexia nervosa. The nurse is monitoring the
behavior of the client and understands that the client with anorexia nervosa manages
anxiety by:

A. Always reinforcing self-approval

B. Having the need to always make the right decision
C. Engaging in immoral acts
D. Observing rigid rules and regulations

Answer: D Rationale: Clients with anorexia nervosa have the desire to please others.
Their need to be correct or perfect interferes with rational decision-making processes.
These clients are moralistic. Rules and rituals help the clients manage their anxiety.
Options 1, 2, and 3 are incorrect

48. A nursing student is developing a plan of care for the hospitalized client with bulimia
nervosa. The nursing instructor intervenes if the student documents which incorrect
intervention in the plan?

A. Monitor intake and output.

B. Monitor electrolyte levels.
C. Observe for excessive exercise.
D. Check for the presence of laxatives and diuretics in the client’s belongings.

Answer: C Rationale: Excessive exercise is a characteristic of anorexia nervosa, not a

characteristic of clients with bulimia. Frequent vomiting, in addition to laxative and
diuretic abuse may lead to dehydration and electrolyte imbalance. Monitoring for
dehydration and electrolyte imbalance are important nursing actions. Option C is the
only option that is not a characteristic of bulima nervosa.

49. A nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal
delirium. The nurse monitors for which of the following?

A. Hypertension, disorientation, hallucinations

B. Hypotension, ataxia, vomiting
C. Stupor, agitation, muscular rigidity
D. Hypotension, coarse hand tremor, agitation

Answer: A Rationale: The symptoms associated with alcohol withdrawal typically are
anxiety, insomnia, anorexia, hypertension, disorientation, visual or tactile hallucinations,
changes in level of consciousness, agitation, fever, and delusions.

5O.The spouse of a client admitted to the hospital for alcohol withdrawal says to the
nurse, “I should get out of this bad situation.” The most helpful response by the nurse
would be:

A. “I agree with you. You should get out of this situation.”

B. “What do you find difficult about this situation?”
C. “Why don’t you tell your husband about this?”
D. “This is not the best time to make that decision.”

Answer: B Rationale: The most helpful response is the one that encourages the client
to problem-solve. Giving advice implies that the nurse knows what is best and can also
foster dependency. The nurse should not agree with the client nor should the nurse
request that the client provide explanations.
51. A nurse is caring for a client who is suspected of being dependent on drugs. Which
question would be most appropriate for the nurse to ask when collecting data from the
client regarding drug abuse?

A. "Why did you get started on these drugs?"

B. "How long did you think you could take these drugs without someone finding out?"
C. "How much do you use and what effect does it have on you?"
D. The nurse does not ask any questions because of fear that the client is in denial and
will throw the nurse out of the room

Answer: C Rationale: Whenever the nurse employs an assessment for a client who is
dependent on drugs, it is best for the nurse to attempt to elicit information by being
nonjudgmental and direct. Option A is incorrect because it is judgmental, off focus, and
reflects the nurse's bias. Option B is incorrect because it is judgmental, insensitive, and
aggressive, which is nontherapeutic. Option D is incorrect because it indicates passivity
on the nurse's part and uses rationalization to avoid the therapeutic nursing intervention

52. A client who has been drinking alcohol on a regular basis admits to having “a
problem” and is asking for assistance with the problem. The nurse would encourage the
client to attend which of the following community groups?

A. Al-Anon
B. Alcoholics Anonymous
C. Families Anonymous
D. Fresh Start

Answer: B Rationale: Alcoholics Anonymous is a major self-help organization for the

treatment of alcoholism. Option A is a group for families of alcoholics. Option C is for
parents of children who abuse substances. Option D is for nicotine addicts.

53. A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a

two-bed hospital room. A newly admitted client will be assigned to this client’s room.
Which client would be an appropriate choice as this client’s roommate?1. A client with
pneumonia2. A client receiving diagnostic tests3. A client who could benefit from the
client’s assistance at mealtime4. A client who thrives on managing others

Answer: B Rationale: The client receiving diagnostic tests is an appropriate roommate.

The client with anorexia is most likely experiencing hematological complications, such as
leukopenia. Having a roommate with pneumonia would place the client with anorexia
nervosa at risk for infection .The client with anorexia nervosa should not be put in a
situation in which he or she can focus on the nutritional needs of others or be managed
by others, because this may contribute to sublimation and suppression of their own
hunger
54. A client has been hospitalized and has participated in substance abuse therapy
group sessions. On discharge, the client has consented to participate in Alcoholics
Anonymous (AA) community groups. Which statement by the client would best indicate
to the nurse that the client has well assimilated therapy session topics and coping
response styles, and has processed information effectively for self-use?

A. “I know I’m ready to be discharged; I feel like I can say ‘no’ and leave a group of
friends if they are drinking. No problem.”
B. “This group has really helped a lot. I know it will be different when I go home. But
I’m sure that my family and friends will all help me like the people in this group have.
They’ll all help me; I know they will. They won’t let me go back to my old ways.”
C. “I’m looking forward to leaving here; I know that I will miss all of you. So, I’m happy
and I’m sad, I’m excited and I’m scared. I know that I have to work hard to be strong
and that everyone isn’t going to be as helpful as you people.”
D . “I’ll keep all my appointments and go to all my AA groups. I’ll do everything I’m
supposed to. Nothing will go wrong that way.”

Answer: C Rationale: In option C, the client is expressing real concern and ambivalence
about discharge from the hospital. The client also demonstrates reality in the statement.
Option A indicates client denial. In option B, the client is relying heavily on others. In
option D, the client is concrete and procedure-oriented; again, the client denies that
“nothing will go wrong that way” if the client follows all the directions.

55. A hospitalized client with a history of alcohol abuse tells the nurse, “I am leaving
now. I have to go. I don’t want any more treatment. I have things that I have to do
right away.” The client has not been discharged. In fact, the client is scheduled for an
important diagnostic test to be performed in 1 hour. After discussing the client’s
concerns with the client, the client dresses and begins to walk out of the hospital room.
The appropriate nursing action is to:

A. Restrain the client until the physician can be reached.

B. Call security to block all exit areas.
C. Tell the client that they cannot return to this hospital again if they leave now.
D. Call the nursing supervisor.

Answer: D Rationale: A nurse can be charged with false imprisonment if a client is

made to wrongfully believe that they cannot leave the hospital. Most health care
facilities have documents that the client is asked to sign, which relate to the client’s
responsibilities when they leave against medical advice (AMA). The client should be
asked to sign this document before leaving. The nurse should request that the client
wait to speak to the physician before leaving but, if the client refuses to do so, the nurse
cannot hold the client against his or her will. Restraining the client and calling security to
block exits constitutes false imprisonment. Any client has a right to healthcare and
cannot be told otherwise
 56. A nursing student is asked to identify the characteristics of bulimia nervosa. The
nursing instructor intervenes if the student identifies which incorrect characteristic of
this disorder?

A. Enlarged parotid glands

B. Dental erosion
C. Electrolyte imbalances
D. Body weight well below ideal range

Answer: D Rationale: Clients with bulimia nervosa may not initially appear to be
physically or emotionally ill. They are often at or slightly below ideal body weight. On
further inspection, the client demonstrates enlargement of the parotid glands with
dental erosion and caries if the client has been inducing vomiting. Electrolyte imbalances
are present

57. A nurse is caring for a client who has a history of opioid abuse and is monitoring the
Clients for signs of withdrawal. Which clinical manifestations are associated withdrawal
from opioids?
A. Yawning, irritability, diaphoresis, cramps, and diarrhea
B. Tachycardia, hypertension, sweating, and marked tremors
C. Increased appetite, irritability, anxiety, and restlessness
D. Depressed feelings, high drug craving, fatigue, and agitation

Answer: A Rationale: Opioids are central nervous system (CNS) depressants.

Withdrawal effects include yawning, insomnia, irritability, rhinorrhea, diaphoresis, cramps,
nausea and vomiting, muscle aches,chills, fever, lacrimation, and diarrhea. Withdrawal is
treated by methadone tapering or medicationdetoxification. Option 1 identifies the clinical
manifestations associated with withdrawal fromopioids. Option 2 describes withdrawal from
alcohol. Option 3 describes withdrawal fromnicotine. Option 4 describes withdrawal from
cocaine.

58. A client is suspected of having systemic lupus erythematous (SLE). The nurse
monitors the client, knowing that which of the following is a characteristic sign of SLE?
1. Rash on the face across the bridge of the nose and on the cheeks
2. Fatigue
3. Fever 
4. Elevated red blood cell count

Answer 1. Rationale: Skin lesions or rash on the face across the bridge of the nose and
on the cheeks is a characteristic sign of SLE. Fever and fatigue may potentially occur before and
during exacerbation. Anemia is most likely to occur in SLE. The nurse provides information to a
client with systemic lupus erythematous (SLE) about measures to manage fatigue.

59. The nurse determines that the client needs additional information if the client states that he
or she will
1. Avoid long periods of rest.
2. Sit whenever possible.
3. Take a hot bath in the evening.
4. Engage in moderate low-impact exercise when not fatigued.

Answer: 3 Rationale: To help reduce fatigue in the client with SLE, the nurse should instruct
the client to sit whenever possible, to avoid hot baths, to schedule moderate low-impact
exercises when not fatigued, and to maintain a balanced diet. The client is instr ucted not to rest
for long periods because it promotes joint stiffness.

60. A client has requested and undergone testing for human immunodeficiency virus (HIV). The
client now asks what will be done next, because the results of two enzyme-linked
immunosorbent assay (ELISA) tests have been positive. The nurse’s response is based on the
understanding that:
1. The client will probably have a bone marrow biopsy done.
2. A Western blot test will be done to confirm these findings.
3. A CD4 +cell count will be obtained to measure T-helper lymphocytes.
4. The client will be definitively diagnosed as HIV-positive at this point.

Answer: 2 Rationale: If the results of two ELISA tests are positive, the Western blot test is
done to confirm the findings. If the result of the Western blot test is positive, then the client is
considered to be positive for HIV and infected with the HIV virus.

61. A nurse is caring for the client with acquired immunodeficiency syndrome (AIDS). The nurse
detects early infection with Pneumocystis jiroveci (formerly called Pneumocystis carinii) by
monitoring the client for which clinical manifestation?
1. Dyspnea on exertion
2. Dyspnea at rest
3. Fever 
4. Cough

Answer: 4 Rationale: The client with  Pneumocystis jiroveci (formerly  P. carinii ) infection
usually has a cough as the first symptom, which begins as nonproductive and then progresses
to productive. Later signs include fever, dyspnea on exertion, and finally dyspnea at rest,

62. A client with acquired immunodeficiency syndrome (AIDS) has a concurrent diagnosis
of histoplasmosis. The nurse notes during data collection that the client has enlarged lymph
nodes.The nurse interprets that:
1. The client has disseminated histoplasmosis infection.
2. This is a side effect of the medications given to treat AIDS.
3. This indicates that the histoplasmosis is resolving.
4. The client probably has yet another infection that is developing.

Answer: 1 Rationale: Histoplasmosis usually starts as a respiratory infection in the client with
AIDS. Itthen becomes a disseminated infection, with enlargement of lymph nodes, spleen, and
liver.Options 2, 3, and 4 are incorrect
63. A client with acquired immunodeficiency syndrome (AIDS) has raised, dark purplish-colored
lesions on the trunk of the body. The nurse anticipates that which procedure will be done to
confirm whether these lesions are due to Kaposi’s sarcoma?
1. Enzyme-linked immunosorbent assay (ELISA)
2. Western blot test
3. Skin biopsy
4. Lung biopsy

Answer: 3 Rationale: The skin biopsy is the procedure of choice to diagnose Kaposi’s sarcoma.
Lung biopsy would confirm Pneumocystis jiroveci(formerlyP. carinii) infection. The ELISA and
Western blot tests are used to diagnose HIV status

64. A nurse participating in a health fair is setting up a booth on prevention of

humanimmunodeficiency virus (HIV) transmission. A poster is planned that will list sexual
behaviors in one of two columns, rated “safe” and “not safe.” Which of the following behaviors
would the nurse place in the “not safe” column?

1. Use of latex condoms

2. Use of “natural skin” condoms
3. Abstinence
4. Mutual monogamy

Answer: 2 Rationale: Abstinence is the safest way to avoid HIV infection. The next most
reliable methodis participation in a mutually monogamous relationship. The use of latex
condoms is consideredsafe, because the latex prevents the transmission of the HIV virus as
long as the condom is used properly and remains in place. The use of “natural skin” condoms is
not considered safe, because the pores in the condom are large enough for the virus to pass
through

65. A client with acquired immunodeficiency syndrome (AIDS) is experiencing nausea and
vomiting. The nurse would suggest which dietary alteration for this client to enhance nutritional
intake?

1. Avoid dairy products and red meat.

2. Plan large, nutritious meals.
3. Add spices to food for added flavor.
4. Serve foods while they are very warm.

Answer: 1 Rationale: The AIDS client with nausea and vomiting should avoid fatty products
such as diary products and red meat. Meals should be small and frequent to lessen the chance
of vomiting. Spices and odorous foods should be avoided, because they aggravate nausea.
Foods are best tolerated either cold or at room temperature
66. A client with pemphigus vulgaris is being seen in the clinic on a regular basis. The
nurse plans care based on which description of this condition?

1. The presence of skin vesicles found along the nerve caused by a virus
2. An autoimmune disorder that causes blistering in the epidermis
3. The presence of red, raised papules and large plaques covered by silvery scales
4. The presence of tiny red vesicles

Answer: 2 Rationale: Pemphigus vulgaris is an autoimmune disease that causes blistering in

the epidermis. The clients have large flaccid blisters (bullae). Because the blisters are in the
epidermis, they have a very tiny covering of skin and break easily, leaving large denuded areas
of skin. On initial examination, clients may have crusting areas instead of intact blisters. Option
1 describes herpes zoster. Option 3 describes psoriasis and option 4 describes eczema.

67. A client is brought to the emergency room and is experiencing an anaphylaxis reaction from
eating shellfish. The nurse prepares for which initial action?

1. Administration of epinephrine (Adrenalin)

2. Administration of a corticosteroid
3. Maintaining a patent airway
4. Instructing the client on the importance of obtaining a Medic-Alert bracelet

Answer: 3 Rationale: The initial action would be to maintain a patent airway. The client would
then receive epinephrine. Corticosteroids may also be prescribed. The client will need to be
instructed about wearing a Medic-Alert bracelet, but this is not the initial action. Test-Taking
Strategy: Use the ABCs—airway, breathing, and circulation—to answer the question. Airway is
always the priority.

68. A nurse is assisting in planning care for a client with a diagnosis of immune deficiency. The
nurse would incorporate which of the following as a priority in the plan of care?

1. Emotional support to decrease fear 

2. Protecting the client from infection
3. Encouraging discussion about lifestyle changes
4. Identifying factors that decreased the immune function

Answer: 2 Rationale: The client with immune deficiency has inadequate or no immune bodies
and is at risk for infection. The priority nursing intervention would be to protect the client from
infection. Options 1, 3, and 4 may be components of care but are not the priority

69. A client calls the nurse in the emergency room and tells the nurse that he was just stung by
a bee while gardening. The client is afraid of a severe reaction, because the client’s
neighbor experienced such a reaction just 1 week ago. The appropriate nursing action is to:
1. Ask the client if he ever received a bee sting in the past
2. Tell the client to call an ambulance for transport to the emergency room.
3. Advise the client to soak the site in hydrogen peroxide.
4. Tell the client not to worry about the sting unless difficulty breathing occurs.

Answer: 1 Rationale: In some types of allergies, a reaction usually occurs only on second and
subsequent contacts with the allergen. The appropriate action, therefore, would be to ask the
client if he ever received a bee sting in the past. Option 2 is unnecessary. Option 3 is not
appropriate advice. The client should not be told “not to worry.

A nurse is assisting in administering immunizations at a health care clinic. The nurse

understands that an immunization will provide:

1. Natural immunity from disease

2. Acquired immunity from disease
3. Innate immunity from disease
4. Protection from all diseases

Answer: 2 Rationale: Acquired immunity can occur by receiving an immunization that causes
antibodies toa specific pathogen to form. Natural (innate) immunity is present at birth. There is
no vaccine for immunization that protects the client from all diseases.

70. A nurse is assigned to care for a client with systemic lupus erythematosus (SLE). The
nurse plans care, knowing that this disorder is:

1. A local rash that occurs as a result of allergy

2. An inflammatory disease of collagen contained in connective tissue
3. A disease caused by overexposure to sunlight
4. A disease caused by the continuous release of histamine in the body

Answer: 2 Rationale: SLE is an inflammatory disease of collagen contained in connective

tissue. Options1, 3, and 4 are not associated with this disease. Test-Taking Strategy:
Knowledge regarding the characteristics of SLE is required to answer this question. Remember,
SLE is an inflammatory disease of collagen contained in connective tissue. Review this disorder
if you had difficulty with this question

71. A nurse is providing home care instructions to a client who has been diagnosed with a latex
allergy. The nurse instructs the client to avoid:

1. Outdoor activities as much as possible

2. Going to parties
3. The use of condoms
4. Sunlight
Answer: 3 Rationale: Mucosal exposure to latex can occur on contact with latex condoms. The
nurse would provide instructions to the client about the need to avoid the use of condoms,
unless they are latex-free. There is no reason to avoid outdoor activities or sunlight. There is
also no reason to avoid parties; however, the client should be informed that certain forms of
balloons are made of latex

72. A nurse is collecting data on a client who has been diagnosed with an allergy to latex. In
determining the client’s risk factors associated with the allergy, the nurse questions the client
about an allergy to which food item?

1. Milk 
2. Bananas
3. Yogurt
4. Eggs

Answer: 2 Rationale: Individuals who are allergic to bananas, avocados, tropical fruits, kiwis,
potatoes, and chestnuts are at risk for developing a latex allergy. This is thought to be caused
by a possible cross-reaction between the food and the latex allergen. Options 1, 3, and 4 are
unrelated to latex allergy

73. A nurse is caring for a client who has returned home from the emergency room following
treatment for a sprained ankle. The nurse notes that the client was sent home with crutches
and needs instructions regarding crutch walking. When collecting data from the client, the
nurse discovers that the client has an allergy to latex. Before providing instructions regarding
crutch walking, the nurse most appropriately:

1. Contacts the physician

2. Covers the crutch pads with cloth
3. Tells the client that the crutches must be removed from the house immediately
4. Calls the local medical supply store and asks for a cane to be delivered

Answer: 2 Rationale: Pads used on crutches contain latex. If the client requires the use of
crutches, the nurse can cover the pads with a cloth to prevent cutaneous contact. Option 3 is
inappropriate and may alarm the client. The nurse cannot order a cane for a client. Additionally,
this type of assistive device may not be appropriate, considering this client’s injury. There is no
reason to contact the physician at this time,

74. A nurse is ordering dressing supplies for a client who has an allergy to latex. The nurse asks
the medical supply personnel to deliver which of the following?

1. Adhesive bandages
2. Elastic bandages
3. Cotton pads and silk tape
4. Brown Ace bandages
Answer: 3 Rationale: Cotton pads and plastic or silk tape are latex-free products. The items
identified inoptions 1, 2, and 4 are all products that contain latex

75. A nurse is providing care of the client following a bone biopsy. Which action by the nurse is
unnecessary in the care of this client?

1. Monitoring the site for swelling, bleeding, hematoma

2. Administering intramuscular narcotic analgesics
3. Elevating the limb for 24 hours
4. Monitoring vitals signs every 4 hours

Answer: 2 Rationale: Nursing care after bone biopsy includes monitoring the site for swelling,
bleeding, and hematoma formation. The biopsy site is elevated for 24 hours to reduce edema.
The vital signs are monitored every 4 hours for 24 hours. The client usually requires mild
analgesics more severe pain usually indicates that complications are arising.

76. A nurse has given dietary instructions to a client to minimize the risk of osteoporosis. The
nurse determines that the client understands the recommended changes if the client verbalizes
to increase intake of which of these foods?

1. Potatoes
2. Cheese
3. Fish
4. Chicken

Answer: 2 Rationale: Calcium intake is important to minimize the risk of osteoporosis. The
major dietary source of calcium is from dairy foods, including milk, yogurt, and a variety of
cheeses. Calcium may also be added to certain products, such as orange juice, which are then
advertised as being“fortified” with calcium. Calcium supplements are available and
recommended for those with typically low calcium intake. Options 1, 3, and 4 are foods that are
not high in calcium

77. A nurse is collecting physical data of the musculoskeletal system on an assigned client. The
nurse would document the presence of which of the following as a normal finding?

1. Presence of fasciculations
2. Atrophy on the client’s dominant side
3. Hypertrophy on the client’s dominant side
4. Atrophy on the client’s nondominant side

Answer: 3 Rationale: Hypertrophy, or increased muscle size on the client’s dominant side of up
to 1 cm, is considered normal. Atrophy on either side is considered an abnormal finding.
Fasciculations are fine muscle twitches that are not normally present.
78. A nurse reviews the activity schedule for the day and determines that the best activity that
the manic client could participate in is:

1. A brown bag lunch and a book review

2. Ping-Pong
3. A paint by number activity
4. A deep breathing and progressive relaxation group.

Answer: 2 Rationale: A person who is experiencing mania is overactive, full of energy, lacks
concentration ,and has poor impulse control. The client needs an activity that will allow him or
her to utilize excess energy, but not endanger others during the process. Options 1, 3, and 4
are relatively sedate activities that require concentration, a quality that is lacking in the manic
state. Suchas activities may lead to increased frustration and anxiety for the client. Ping-Pong is
an activity that will help to expend the increased energy this client is experiencing.

79. A client is being treated for depression with amitriptyline hydrochloride (Elavil). During
theinitial phases of treatment, the most important nursing intervention is:1. Ordering the client
an tyramine-free diet2. Recognizing that monitoring blood levels frequently is necessary,
because there is a narrowrange between therapeutic and toxic blood levels of this medication3.
Getting baseline postural blood pressures on the client before administering the medicationand
each time the medication is dispensed to the client, especially during the initial days
of treatment4. Checking the client for anticholinergic effects

Answer: 3 Rationale: Amitriptyline hydrochloride is a tricyclic antidepressant often used to

treat depression. It causes orthostatic changes and can produce hypotension and tachycardia.
This can be frightening to the client and dangerous, because it could result in dizziness and
client falls. The client must be instructed to move slowly from a lying to a sitting to a standing
position to avoid injury if these effects are experienced. The client may also experience
sedation, dry mouth, constipation, blurred vision, and other anticholinergic effects, but these
are transient and will diminish with time

80. A nurse is reviewing the health care record of a client admitted to the psychiatric unit. The
nurse notes that the admission nurse has documented that the client is experiencing anxiety as
a result of a situational crisis. The nurse would determine that this type of crisis could be
caused by:

1. A fire that destroyed the client’s home

2. A recent rape episode experienced by the client
3. The death of a loved one
4. Witnessing a murder 

Answer: 3 Rationale: A situational crisis arises from external rather than internal sources.
External situations that could precipitate a situational crisis include loss or change of a job, the
death of a loved one, abortion, change in financial status, divorce, addition of new family
members, pregnancy, and severe illness. Options 1, 2, and 4 identify adventitious crisis. An
adventitious crisis is not a part of everyday life, is unplanned, and is accidental.

81.A nurse is gathering data from a client in crisis. When determining the client’s perception
of the precipitating event that led to the crisis, the most appropriate question to ask is:

1. “What leads you to seek help now?”

2. “Who is available to help you?”
3. “What do you usually do to feel better?”
4. “With whom do you live?”

Answer: 1 Rationale: A nurse’s initial task when gathering data from a client in crisis is to
assess the individual or family and the problem. The more clearly the problem can be defined,
the better the chance a solution can be found. Option 1 will assist in determining data related
to the precipitating event that led to the crisis. Options 2 and 4 identify situational supports.
Option 3identifies personal coping skills

82. A nurse is assisting in developing a plan of care for the client in a crisis state. When
developing the plan, the nurse will consider which of the following?

1. Presenting symptoms in a crisis situation are similar for all individuals experiencing a crisis.
2. A crisis state indicates that the individual is suffering from an emotional illness.
3. A crisis state indicates that the individual is suffering from a mental illness.
4. A client’s response to a crisis is individualized, and what constitutes a crisis for one person
may not constitute a crisis for another person

Answer: 4 Rationale: Although each crisis response can be described in similar terms as far as
presenting symptoms are concerned, what constitutes a crisis for one person may not
constitute a crisis for another person, because each is a unique individual. Being in a crisis state
does not mean that the client is suffering from an emotional or mental illness

83. A nurse observes that a client with a potential for violence is agitated, pacing up and down
in the hallway, and making aggressive and belligerent gestures at other clients. Which
statement would be appropriate to make to this client?

1. “What is causing you to become agitated?”

2. “You need to stop that behavior now!”
3. “You will need to be restrained if you do not change your behavior.”
4. “You will need to be placed in seclusion!

Answer: 1 Rationale: The best statement is to ask the client what is causing the agitation. This
will assist the client to become aware of the behavior and will assist the nurse in planning
appropriate interventions for the client. Option 2 is demanding behavior, which could cause
increased agitation in the client. Options 3 and 4 are threats to the client and are inappropriate
84. During a conversation with a depressed client on a psychiatric unit, the client says to the
nurse, “My family would be better off without me.” The nurse should make which the
rapeuticresponse to the client?
1. “Everyone feels this way when they are depressed.”
2. “Have you talked to your family about this?”
3. “You sound very upset. Are you thinking of hurting yourself?”
4. “You will feel better once your medication begins to work.”

Answer: 3 Rationale: Clients who are depressed may be at risk for suicide. It is critical for the
nurse toassess suicidal ideation and plan. The client should be directly asked if a plan for self-
harmexists. Options 1, 2, and 4 are not therapeutic responses

85. Which behaviors observed by the nurse might lead to the suspicion that a depressed
adolescent client could be suicidal?

1. The client becomes angry while speaking on the telephone and slams the receiver down on
the hook.
2. The client runs out of the therapy group swearing at the group leader, and runs to her room.
3. The client gets angry with her roommate when the roommate borrows her clothes without
asking.
4. The client gives away a prized CD and a cherished autographed picture of the performer.

Answer: 4 Rationale: A depressed, suicidal client often gives away that which is of value as a
way of saying “goodbye” and wanting to be remembered. Options 1, 2, and 3 identify acting-
out behaviors.

86. A client is admitted to the psychiatric unit following a serious suicidal attempt by hanging.
The nurse’s most important aspect of care is to maintain client safety and plans to:

1. Assign a staff member to the client who will remain with the client at all times.
2. Admit the client to a seclusion room where all potentially dangerous articles are removed.
3. Remove the client’s clothing and place the client in a hospital gown.
4. Request that a peer remain with the client at all times.

Answer: 1 Rationale: Hanging is a serious suicide attempt. The plan of care must reflect action
that will promote the client’s safety. Constant observation status (one on one) with a staff
member who is never less than an arm’s length away is the safest intervention

87. The police arrive at the emergency room with a client who has seriously lacerated both
wrists. The initial nursing action is to:

1. Examine and treat the wound sites.

2. Secure and record a detailed history.
3. Encourage and assist the client to ventilate feelings.
4. Administer an antianxiety agent.
Answer: 1 Rationale: The initial nursing action is to examine and treat the self-inflicted
injuries. Injuries from lacerated wrists can lead to a life-threatening situation. Other
interventions may follow after the client has been treated medical

88. A nurse receives a telephone call from a male client who states that he wants to kill
himself and has a bottle of sleeping pills in front of him. The best nursing action is to:

1. Insist that the client give you his name and address so that you can get the police there
immediately.
2. Keep the client talking and allow the client to ventilate feelings.
3. Use therapeutic communications, especially the reflection of feelings.
4. Keep the client talking and signal to another staff member to trace the call so that
appropriate help can be sent.

Answer: 4 Rationale: In a crisis, the nurse must take an authoritative, active role to promote
the client’s safety. A bottle of sleeping pills in front of a client who verbalizes he wants to kill
himself is a “crisis.” The client’s safety is of prime concern. Keeping the client on the phone and
getting help to the client is the best intervention. The word “insist” could anger the client, and
he might hang up. Option 2 lacks the authoritative action stance of securing the client’s safety.
Using therapeutic communication is important, but overuse of “reflection” may sound uncaring
or superficial and is lacking direction and solutions to the immediate problem of the client’s
safety nurse is caring for a client with severe depression.

89. A client experiencing a severe major depressive episode is unable to address activities
of daily living. The most appropriate nursing intervention is to:

1. Feed, bathe, and dress the client as needed until the client can perform these activities
independently.
2. Structure the client’s day so that adequate time can be devoted to the client’s assuming
responsibility for the activities of daily living.
3. Offer the client choices and consequences to the failure to comply with the expectation
of maintaining activities of daily living.
4. Have the client’s peers confront the client about how the noncompliance in addressing
activities of daily living affects the milieu

Answer: 1 Rationale: The client with depression may not have the energy or interest to
complete activities of daily living. Often, severely depressed clients are unable to perform even
the simplest activities of daily living. The nurse assumes this role and completes these tasks
with the client. Options 2 and 3 are incorrect because the client lacks the energy and motivation
to perform these tasks independently. Option 4 will increase the client’s feelings of poor self-
esteem and unworthiness.

90. A nurse is assisting in planning care for a client being admitted to the nursing unit who has
attempted suicide. Which priority nursing intervention will the nurse include in the plan of care?
1. Check the whereabouts of the client every 15 minutes.
2. Suicide precautions, with 30-minute checks.
3. One-to-one suicide precautions.
4. Ask that the client report suicidal thoughts immediately.

Answer: 3 Rationale: One-to-one suicide precautions are required for the client who has
attempted suicide. Options 1 and 2 are not appropriate, considering the situation. Option 4 may
be an appropriate nursing intervention, but the priority is stated in option 3. The best option is
constant supervision so that the nurse may intervene as needed if the client attempts to cause
harm to himself or herself.

90. An older male client who is a victim of elder abuse and the client’s family have been
attending weekly counseling sessions. Which statement by the abusive family member would
indicate that he or she has learned positive coping skills?
1. "I will be more careful to make sure that my father's needs are met."
2. "I am so sorry and embarrassed that the abusive event occurred. It won't happen again."
3. "I feel better able to care for my father now that I know where to obtain assistance."
4. "Now that my father is moving into my home, I will need to change my ways."

Answer: 3 Rationale: Elder abuse sometimes occurs when family members who are being
expected to care for their aging parents. This can cause family members to become
overextended, frustrated, or financially depleted. Knowing where in the community to turn for
assistance in caring for aging family members can bring much needed relief. Using these
alternatives is a positive alternative coping strategy, which many families use.

91.A client with trigeminal neuralgia tells the nurse that acetaminophen (Tylenol) is taken on a
frequent daily basis for relief of generalized discomfort. The nurse reviews the client’s
laboratory results and determines that which of the following indicates toxicity associated with
the medication?
1. Platelet count of 400,000 cells/ µl
2. A direct bilirubin level of 2 mg/dl
3. Prothrombin time of 12 seconds
4. Sodium of 140 mEq/L

Answer: 2 Rationale: In adults, overdose of acetaminophen (Tylenol) causes liver damage.

Option 2 is an indicator of liver function, and is the only option that indicates an abnormal
laboratory value.The normal direct bilirubin is 0 to 0.4 mg/dl. The normal platelet count is
150,000 to 400,000cells/ µ l. The normal prothrombin time is 10 to 13 seconds. The normal
sodium level is 135 to145 mEq/L.

92. A client is receiving baclofen (Lioresal) for muscle spasms due to a spinal cord injury. The
nurse monitors the client, knowing that which of the following is a side effect of this
medication?
1. Photosensitivity
2. Slurred speech
3. Hypertension
4. Muscle pain

Answer: 2 Rationale: Side effects of baclofen (Lioresal) include drowsiness, dizziness,

weakness, and nausea. Occasional side effects include headache, paresthesia of the hands and
feet, constipation or diarrhea, anorexia, hypotension, confusion, and nasal congestion.
Paradoxical central nervous system excitement and restlessness can occur, along with slurred
speech, tremors

93. A client is suspected of having myasthenia gravis and the physician administers
edrophonium(Tensilon) intravenously to determine the diagnosis. Following administration of
thismedication, which of the following would indicate the presence of myasthenia gravis?
1. An increase in muscle strength
2. A decrease in muscle strength
3. Joint pain
4. Feelings of faintness, dizziness, hypotension, and signs of flushing in the client

Answer: 1 Rationale: Edrophonium (Tensilon) is a short-acting acetylcholinesterase inhibitor

used as a diagnostic agent. When a client with suspected myasthenia gravis is given the
medication intravenously, an increase in muscle strength would be seen in 1 to 3 minutes. If no
response occurs, another dose of edrophonium (Tensilon) is given over the next 2 minutes and
muscles strength is again tested. If no increase in muscle strength occurs with this higher dose,
the muscle weakness is not caused by myasthenia gravis. Clients receiving injections of this
medication commonly demonstrate a drop of blood pressure, feel faint and dizzy, and are
flushed

94. A nurse is planning care for a client who is being hospitalized because the client has been
displaying violent behavior and is at risk for potential harm to others. The nurse avoids which
intervention in the plan of care?

1. Keeping the door to the client’s room open when with the client
2. Assigning the client to a room at the end of the hall to avoid disturbing the other clients
3. Facing the client when providing care
4. Ensuring that a security officer is within the immediate area

Answer: 2 Rationale: The client should be placed in a room near the nurses’ station and not at
the end of along, relatively unprotected corridor. The nurse should not isolate himself or herself
with a potentially violent client. The door to the client’s room should be kept open, and the
nurse should never turn away from the client. A security officer or male aide should be within
immediate call in case of a suspicion of the possibility of violence.

95. A client with myasthenia gravis is suspected of having cholinergic crisis. Which of the
following would indicate that this crisis exists?

1. Hypotension
2. Hypertension
3. Mouth sores
4. Ataxia
Answer: 2 Rationale: Cholinergic crisis occurs as a result of an overdose of medication.
Indications of cholinergic crisis includes gastrointestinal disturbances, nausea, vomiting,
diarrhea, abdominal cramps, increased salivation and tearing, miosis, hypertension, sweating,
and increased bronchia secretions client with myasthenia gravis is receiving pyridostigmine
(Mestinon).

 
96. The nurse monitors for signs and symptoms of cholinergic crisis caused by overdose of the
medication. The nurse checks the medication supply to ensure that which medication is
available for administration if acholinergic crisis occurs?
1. Vitamin K 
2. Protamine sulfate
3. Acetylcysteine (Mucomyst)
4. Atropine sulfate

Answer: 4 Rationale: The antidote for cholinergic crisis is atropine sulfate. Vitamin K is the
antidote for warfarin (Coumadin). Protamine sulfate is the antidote for heparin, and
acetylcysteine (Mucomyst) is the antidote for acetaminophen (Tylenol

97. A nurse is caring for an older adult client who has recently lost her husband. The client
says,"No one cares about me anymore. All the people I loved are dead." Which response by the
nurse is therapeutic?

1. "That seems rather unlikely to me."

2. "You must be feeling all alone at this point."
3. "I don't believe that, and neither do you."
4. "Right! Why not just ‘pack it in’?"

Answer: 2 Rationale: The client is experiencing loss and is feeling hopeless. The therapeutic
response by the nurse is the one that attempts to translate words into feelings. In option 1, the
nurse is voicing doubt, which is often used when a client verbalizes delusional ideas. In option
3, the nurse is disagreeing with the client, which implies that the nurse has passed judgment on
the client's ideas or opinions. In option 4, the nurse uses sarcasm, which gives advice and is
non therapeutic as a nursing response

98. A client with possible rib fracture has never had a chest x-ray. The nurse would plan to tell
the client which of the following items about the procedure?

1. The x-ray stimulates a small amount of pain.

2. It is necessary to remove jewelry and any other metal objects.
3. The client will be asked to breathe in and out during the x-ray.
4. The x-ray technologist will stand next to the client during the x-ray.
Answer: 2 Rationale: An x-ray is a photographic image of a part of the body on a special film,
which is used to diagnose a wide variety of conditions. The x-ray itself is painless; any
discomfort would arise from repositioning a painful part for filming. The nurse may want to
premedicate a client who is at risk for pain. Any radiopaque objects such as jewelry or other
metal must be removed. The client is asked to breathe in deeply and then hold the breath while
the chest x-ray is taken. To minimize risk of radiation exposure, the x-ray technologist stands in
a separate area protected by a lead wall. The client also wears a lead shield over the genital
area

99.A client has had a bone scan procedure. The nurse determines that the client understands
the elements of follow-up care if the client states that he or she will:

1. Report any feelings of nausea or flushing.

2. Ambulate at least three times before the end of the day.
3. Eat only small meals for the remainder of the day.
4. Drink plenty of water for a day or two following the procedure.

Answer: 4 Rationale: There are no special restrictions following a bone scan. The client is
encouraged to drink large amounts of water for 24 to 48 hours to flush the radioisotope from
the system. There are no hazards to the client or staff from the minimal amount of radioactivity
of the isotope

100. A client seeks treatment in the emergency room for a lower leg injury. There is visible
deformity to the lower aspect of the leg, and the injured leg appears shorter than the other.
The area is painful, swollen, and beginning to become ecchymotic. The nurse interprets that
this client has experienced a:
1. Contusion
2. Fracture
3. Sprain
4. Strain

Answer: 2 Rationale: Typical signs and symptoms of fracture include pain, loss of function in
the area, deformity, shortening of the extremity, crepitus, swelling, and ecchymosis. Not all
fractures lead to the development of every sign. A contusion results from a blow to soft tissue
and causes pain, swelling, and ecchymosis. A sprain is an injury to a ligament caused by a
wrenching or twisting motion. Symptoms include pain, swelling, and inability to use the joint or
bear weight normally. A strain results from a pulling force on the muscle. Symptoms include
soreness and pain with muscle use,

101.A nurse witnesses a client sustain a fall and suspects that the client’s leg may be fractured.
Which action is the priority?
1. Take a set of vital signs.
2. Call the radiology department.
3. Reassure the client that everything will be fine.
4. Immobilize the leg before moving the client.

Answer: 4 Rationale: When a fracture is suspected, it is imperative that the area is splinted
before the client is moved. Emergency help should be called for if the client is not hospitalized,
and a physician is called for the hospitalized client. The nurse should remain with the client and
provide realistic reassurance. The nurse does not prescribe radiology tests

102.A nurse provides cast application instructions to a client who is going to have a plaster
castapplied. The nurse determines that the client needs further instructions if the client states
that:

1. A stockinette will be placed over the leg area to be casted.

2. The cast edges may be trimmed with a cast knife.
3. The cast will give off heat as it dries.
4. The client may bear weight on the cast in 30 minutes.

Answer: 4 Rationale: The procedure for casting involves washing and drying the skin and
placing a stockinette material over the area to be casted. A roll of padding is then applied
smoothly and evenly. The plaster is rolled onto the padding, and the edges are trimmed or
smoothed as needed. A plaster cast gives off heat as it dries. A plaster cast can tolerate weight-
bearing once it is dry, which varies from 24 to 72 hours, depending on the nature and thickness
of the cast

103. A client has a fiberglass (nonplaster) cast applied to the lower leg. The client asks the
nurse when he will be able to walk on the cast. The nurse replies that the client will be able to
bear weight on the cast:

1. Within 20 to 30 minutes of application

2. In approximately 8 hours
3. In 24 hours
4. In 48 hours
Answer: 1 Rationale: A fiberglass cast is made of water-activated polyurethane materials,
which are dry to the touch within minutes and reach full rigid strength in about 20 minutes.
Because of this, the client can bear weight on the cast within 20 to 30 minutes

104. A nurse has reinforced instructions with the client with a nonplaster (fiberglass) leg cast
about cast care at home. The nurse determines that the client needs further instructions if the
client makes which statement?

1. “I should avoid walking on wet, slippery floors.”

2. “It’s all right to wipe dirt off the top of the cast with a damp cloth.”
3. “I’m not supposed to scratch the skin underneath the cast.  
4. “If the cast gets wet, I can dry it with a hair dryer turned to the warmest setting.”
Answer: 4 Rationale: Client instructions should include avoidance of walking on wet, slippery
floors to prevent falls. Surface soil on a cast may be removed with a damp cloth. If the cast
gets wet, it can be dried with a hair dryer set to a cool setting to prevent skin breakdown. If the
skin under the cast itches, cool air from a hair dryer may be used to relieve it. The client should
never scratch under a cast because of risk of skin breakdown and ulcer formation

105. A client in skeletal leg traction with an overbed frame is not allowed to turn from side to
side. Which action by the nurse would be most useful in trying to provide good skin care of the
client ?

1. Asking the client to lift up by digging into the mattress with the unaffected leg
2. Pushing down on the mattress of the bed while administering care
3. Having another nurse tilt the client to the side
4. Asking the client pull up on a trapeze to lift the hips off the bed

Answer: 4 Rationale: If the client in skeletal traction may not turn from side to side, the nurse
should have the client pull up on a trapeze and try to lift the hips off the bed for skin care, bed
pan use, and linen changes. If the client is unable to pull up on a trapeze, the nurse can push
down on the mattress with one hand while administering care with the other

106. A client has Buck’s extension traction applied to the right leg. The nurse would plan which
intervention to prevent complications of the device?

1. Massaging the skin of the right leg with lotion every 8 hours
2. Giving pin care once a shift
3. Inspecting the skin on the right leg at least once every 8 hours
4. Releasing the weights on the right leg for range-of-motion exercises daily

Answer: 3 Rationale: Buck’s extension traction is a type of skin traction. The nurse
inspects the skin of the limb in traction at least once every 8 hours for irritation or
inflammation. Massaging the skin with lotion is not indicated. The nurse never releases the
weights of traction unless specifically ordered by the physician. There are no pins to care for
with skin traction

107. A nurse has reinforced instructions regarding specific leg exercises for the client
immobilized in right skeletal lower leg traction. The nurse determines that the client needs
further instruction if the nurse observes the client:

1. Pulling up on the trapeze

2. Flexing and extending the feet
3. Performing active range of motion to the right ankle and knee
4. Doing quadriceps-setting and gluteal-setting exercises
Answer: 3 Rationale: Exercise is indicated within therapeutic limits for the client in skeletal
traction to maintain muscle strength and range of motion. The client may pull up on the
trapeze, perform active ROM with uninvolved joints, and do isometric muscle-setting exercises
(e.g., quadriceps-and gluteal-setting exercises). The client may also flex and extend his or her
feet.

108. A client with myasthenia gravis becomes increasingly weaker. The physician prepares to
identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or to
increasing severity of the disease (myasthenic crisis). An injection of edrophonium (Tensilon) is
administered. Which of the following would indicate that the client is in cholinergic crisis?

1. An improvement of the weakness

2. A temporary worsening of the condition
3. No change is the condition
4. Complaints of muscle spasms
ANSWER 2. Rationale. An edrophonium (Tensilon) injection makes the client in cholinergic crisis
temporarily worse. This is known as a negative Tensilon test. An improvement of weakness
would occur if the client were experiencing myasthenia gravis. Options 3 and 4 would not
occur in either crisis

109. A client with myasthenia gravis verbalizes complaints of feeling much weaker than normal.
The physician plans to implement a diagnostic test to determine if the client is experiencing a
myasthenic crisis and administers edrophonium (Tensilon). Which of the following wouldindicate
that the client is experiencing a myasthenic crisis?
1. Increasing weakness
2. No change in the condition
3. A temporary improvement in the condition
4. An increase in muscle spasms

Answer: 3 Rationale: Edrophonium (Tensilon) is administered to determine whether the client

is reacting to an overdose of a medication (cholinergic crisis) or to an increasing severity of the
disease (myasthenic crisis). When the edrophonium (Tensilon) injection is given and the
condition improves temporarily, the client is in myasthenic crisis. This is known as a positive
Tensilon test. Increasing weakness would occur in cholinergic crisis. Options 3 and 4 would not
occur ineither crisis.

A client is taking phenytoin (Dilantin) for seizure control and a sample for a serum druglevel is
drawn. Which of the following would indicate a therapeutic serum drug range?
1. 5 to 10µg/mL
2. 10 to 20µg/mL
3. 20 to 30µg/mL
4. 30 to 40µ g/mL

Answer: 2 Rationale: The therapeutic serum drug level range for phenytoin (Dilantin) is 10 to
20
µg/mL.
110.A nursing student is presenting a clinical conference and discusses the causative factors
related toβ-thalassemia. The student informs the group that the child at greatest risk
of developing this disorder is:
1. A child whose intake of iron is extremely poor 
2. A child breast-fed by a mother with chronic anemia
3. A child of Mediterranean descent
4. A child of Mexican descent

Answer: 3 Rationale:β-Thalassemia is an autosomal recessive disorder. This disorder is found

primarily in individuals of Mediterranean descent. The disease has also been reported in Asian
and African populations.

111.A nurse reinforces instructions to the parents of a child with leukemia regarding measures
related to monitoring for infection. Which statement by the parents indicates a need for
further instructions?
1. “I need to use proper hand washing techniques.”
2. “I need to take a rectal temperature daily on my child.”
3. “I need to inspect my child’s skin daily for redness.”
4. “I need to inspect my child’s mouth daily for lesions.”

Answer: 2 Rationale: The risk of injury to fragile mucous membranes is so great in the child
with leukemia that only oral, axillary, or tympanic temperatures should be taken. Rectal
abscesses can easily occur in damaged rectal tissue. No rectal temperatures should be taken.
Additionally, oral temperatures should be avoided if the child has oral ulcers. Options 1, 3, and
4 are appropriate teaching measures.

112.A 6-year-old child with leukemia is hospitalized and is receiving chemotherapy. Laboratory
results indicate that the child is neutropenic and protective isolation procedures are initiated.
The grandmother of the child visits and brings a fresh bouquet of flowers picked from her
garden and asks the nurse for a vase for the flowers. The nurse makes which appropriate
response to thegrandmother?
1. “I have a vase in the utility room and I will get it for you.”
2. “The flowers from your garden are beautiful, but should not be placed in the child’s room
atthis time.”
3. “I will get the vase and wash it well before you put the flowers in it.”
4. “When you bring the flowers into the room, place them on the bedside stand as far away
fromthe child as possible.”

Answer: 2 Rationale: For the hospitalized neutropenic child, flowers or plants should not be
kept in the room because standing water and damp soil harbor  Aspergillus And  Pseudomonas
organisms, to which these children are very susceptible. Additionally, fruits and vegetables that
are not peeled before being eaten harbor molds and should be avoided until the white blood
cell count rise

113. A nurse is reviewing the health record of a 10-year-old child suspected of having
Hodgkin’sdisease. Which of the following would the nurse expect to note documented in the
record that is most characteristic of this disease?
1. Painful, enlarged inguinal lymph nodes
2. Fever and malaise
3. Painless, firm, and movable adenopathy in the cervical area
4. Anorexia and weight loss

Answer: 3 Rationale: Clinical manifestations specifically associated with Hodgkin’s disease

include painless, firm, and movable adenopathy in the cervical and supraclavicular areas.
Hepatosplenomegaly is also noted. Although anorexia, weight loss, fever, and malaise are
associated with Hodgkin’s disease, these manifestations are seen in many disorders

114.A 4-year-old child is hospitalized with a suspected diagnosis of Wilms’ tumor. The
nurseassists in developing a plan of care and suggests avoiding which of the following?1.
Palpating the abdomen for a mass
2. Checking the urine for the presence of hematuria
3. Monitoring the temperature for the presence of fever 
4. Monitoring the blood pressure for the presence of hypertension

Answer: 1 Rationale: A Wilms’ tumor is a tumor of the kidney. If Wilms’ tumor is suspected, the mass should
not be palpated. Excessive manipulation can cause seeding of the tumor and cause the spread
of the cancerous cells. Fever, hematuria, and hypertension are clinical manifestations associated
with Wilms’ tumor

115. A nursing instructor asks a student nurse to describe osteogenic sarcoma. Which
statement by the student indicates the need to further research the disease?
1. “The symptoms of the disease in the early stage are almost always attributed to normal
growing pains.”
2. “The femur is the most common site of this sarcoma.”
3. “Limping, if a weight bearing limb is affected, is a clinical manifestation.”
4. “The child does not experience pain at the primary tumor site.”

Answer: 4 Rationale: A clinical manifestation of osteogenic sarcoma is progressive, insidious,

intermittent pain at the tumor site. By the time these children receive medical attention, they
may be inconsiderable pain from the tumor. Options 1, 2, and 3 are accurate regarding
osteogenic sarcoma.

116 A 13-year-old child is diagnosed with Ewing’s sarcoma of the femur. Following a course
of chemotherapy, it has been decided that leg amputation is necessary. Following the
amputation,the child becomes very frightened because of aching and cramping felt in the
missing limb. The nurse makes which statement to assist in alleviating the child’s fear?

1. “This aching and cramping is normal and temporary and will subside.”
2. “This always occurs after the surgery and we will teach you ways to deal with it.”
3. “The pain medication that I give you will take these feelings away.
4. “This pain is not real pain and relaxation exercises will help it go away.”

Answer: 1 Rationale: Following amputation, phantom limb pain is a temporary condition that
some children may experience. This sensation of aching or cramping in the missing limb is most
distressing to the child. The child needs to be reassured that the condition is normal and only
temporary

117. A nurse is monitoring for bleeding in a child following surgery for removal of a brain
tumor. The nurse checks the head dressing for the presence of blood and notes a colorless
drainage on the back of the dressing. The nurse takes which appropriate action?

1. Circles the area of drainage and continues to monitor 

2. Reinforces the dressing
3. Notifies the registered nurse (RN)
4. Documents the findings and continue to monitor 

Answer: 3 Rationale: Colorless drainage on the dressing would indicate the presence of
cerebrospinal fluidand should be reported to the RN immediately. The RN would then contact
the physician.Options 1, 2, and 4 delay required immediate interventions

118. A child with rubeola (measles) is being admitted to the hospital. In preparing for the
admission of the child, the nurse plans to institute which precaution for this child?

1. Contact
2. Enteric
3. Respiratory
4. Protective

Answer: 3 Rationale: Rubeola is transmitted via airborne particles or direct contact with
infectious droplets.Respiratory precautions are required and a mask is worn by those in contact
with the child.Gowns and gloves are not indicated. Articles that are contaminated should be
bagged andlabeled. Options 1, 2, and 4 are not indicated in rubeola.

119. Several children have contracted rubeola (measles) in a local school and the school nurse
conducts a teaching session for the mothers of the schoolchildren. Which statement made by a
mother indicates a need for further teaching regarding this communicable disease?

1. “Respiratory symptoms such as a very runny nose, cough, and fever occur before the
development of a rash.”
2. “Small blue-white spots with a red base may appear in the mouth.”
3. “The rash usually begins behind the ears and spreads downward toward the feet.”
4. “The communicable period ranges from 10 days before the onset of symptoms to 15 days
after the rash appears.”

Answer: 4 Rationale: The communicable period for rubeola ranges from 4 days before to 5
days after the rash appears, mainly during the prodromal (catarrhal) stage. Options 1, 2, and 3
are accurate descriptions of rubeola. The small blue-white spots found in this communicable
disease are called Koplik spots. Option 4, the incorrect option, describes the incubation period
for rubella, not rubeola
120. A mother of a 15-month-old child brings the child to the clinic and reports that the child
has a fever and has developed a rash on the neck and trunk. Roseola is diagnosed, and the
mother is concerned that her other children will contract the disease. The nurse provides which
instruction to the mother regarding prevention of transmission of the disease?

1. The disease is transmitted through the urine and feces, so the other children should use a
separate bathroom.
2. Disease transmission is unknown.
3. The disease is transmitted through the respiratory tract, so the child should be isolated from
the other children as much as possible.
4. The disease is transmitted by contact with body fluids, so any items contaminated with body
fluids need to discarded in a separate receptacle.

Answer: 2 Rationale: The method of transmission of roseola is unknown. Options 1, 3, and 4

are not correct transmission routes of roseola.

121.The nurse provides instructions regarding respiratory precautions to the mother of a child
with mumps. The mother asks the nurse about the length of time required for the
respiratory precautions. The nurse tells the mother that:
1. Respiratory isolation in not necessary.
2. Mumps is not transmitted by the respiratory system.
3. Respiratory precautions are indicated during the period of communicability.
4. Respiratory precautions are indicated for 18 days following the onset of parotid swelling.

Answer: 3 Rationale: Mumps is transmitted via direct contact or droplet spread from an
infected person and possibly by contact with urine. Respiratory precautions are indicated during
the period of communicability. Options 1, 2, and 4 are incorrect

122. The mother brings her 6-year-old child to the clinic because the child has developed a rash
on the trunk and on the scalp. The mother reports that the child has had a low-grade fever, has
not felt like eating, and has been generally tired. The child is diagnosed with chickenpox, and
the mother inquires about the communicable period associated with chickenpox. The nurse
plans to base the response on which of the following?1. The communicable period is
unknown.2. The communicable period is 1 to 2 days before the onset of the rash to 6 days
after the onset and crusting of lesions.3. The communicable period is 10 days before the onset
of symptoms to 15 days after the rashappears.4. The communicable period ranges from 2
weeks or less up to several months.

Answer: 2 Rationale: The communicable period for chickenpox is 1 to 2 days before the onset
of the rash to 6 days after the onset and crusting of lesions. In roseola, the communicable
period is unknown. Option 3 describes rubella. Option 4 describes diphtheria

123.A nurse is checking the casted extremity of a client. The nurse would check for which of
the following signs and symptoms indicative of infection?

1. Coolness and pallor of the extremity

2. Presence of a “hot spot” on the cast
3. Diminished distal pulse
4. Dependent edema

Answer: 2 Rationale: Signs and symptoms of infection under a casted area include odor or
purulent drainage from the cast, or the presence of “hot spots,” which are areas of the cast that
are warmer than others. The physician should be notified if any of these occur. Signs of
impaired circulation in the distal limb include coolness and pallor of the skin, diminished arterial
pulse, and edema

123. The nurse reinforces home care instructions to the parents of a child hospitalized
with pertussis who is in the convalescent stage and is being prepared for discharge. Which
statement by the parents indicates a need for further instructions

1. “We need to maintain respiratory precautions and a quiet environment for at least 2 weeks.”
2. “Coughing spells may be triggered by dust or smoke.”
3. “We need to encourage an adequate fluid intake.”
4. “Good hand washing techniques must be instituted to prevent spreading the disease to
others.”

]Answer: 1 Rationale: Pertussis is transmitted by direct contact or respiratory droplets from

coughing. The communicable period occurs primarily during the catarrhal stage. Respiratory
precautions are not required during the convalescent phase. Options 2, 3, and 4 are
components of home care instructions.

124.A 6-month-old infant receives a DTaP (diphtheria, tetanus, and a cellular

pertussis)immunization at the well-baby clinic. The mother returns home and calls the clinic to
report that he infant has developed swelling and redness at the site of injection. The nurse tells
the mother to:

1. Leave the injection site alone because this always occurs

2. Bring the infant back to the clinic
3. Apply an ice pack to the injection site
4. Monitor the infant for a fever 

Answer: 3 Rationale: Occasionally, tenderness, redness, or swelling may occur at the site of
the injection. This can be relieved with ice packs for the first 24 hours, followed by warm
compresses if the inflammation persists. It is not necessary to bring the infant back to the clinic.
Option 4 may be an appropriate intervention but is not specific to the issue of the question.

125. A client has sustained a closed fracture and has just had a cast applied to the affected
arm. The client is complaining of intense pain. The nurse has elevated the limb, applied an ice
bag, and administered an analgesic, which was ineffective in relieving the pain. The nurse
interprets that this pain may be caused by:
1. Impaired tissue perfusion
2. The newness of the fracture
3. The anxiety of the client
4. Infection under the cast

Answer: 1 Rationale: Most pain associated with fractures can be minimized with rest,
elevation, application of cold, and administration of analgesics. Pain that is not relieved from
these measures should be reported to the physician, because it may be the result of impaired
tissue perfusion, tissue breakdown, or necrosis. Because this is a new closed fracture and cast,
infection would not have had time to set in

126. A nurse is assigned to care for a client with multiple trauma who is admitted to the
hospital. The client has a leg fracture and a plaster cast has been applied. In positioning the
casted leg, the nurse should:

1. Keep the leg in a level position.

2. Keep the leg level for 3 hours, and elevate it for 1 hour.

3. Elevate the leg on pillows continuously for 24 to 48 hour

4. Elevate the leg for 3 hours, and put it flat for 1 hour.

Answer: 3 Rationale: A casted extremity is elevated continuously for the first 24 to 48 hours to
minimize swelling and to promote venous drainage.

127. A child is scheduled to receive an MMR (measles, mumps, rubella) vaccine. The
nurse preparing to administer the vaccine reviews the child’s record and questions the order if
which of the following is documented in the child’s record?

1. A local reaction at the site of a previous MMR vaccine injection

2. A history of an anaphylactoid reaction to neomycin
3. A history of frequent respiratory infections
4. Recent recovery from a cold

Answer: 2 Rationale: MMR vaccine contains minute amounts of neomycin. A history of an

anaphylactoid reaction to neomycin is considered a contraindication to the MMR vaccine. The
general contraindication to all immunizations is a severe febrile illness. The presence of minor
illnesses such as a common cold is not a contraindication. Additionally, a history of frequent
respiratory infections is not a contraindication to receiving a vaccine. A local reaction to an
immunization is treated with ice packs for the first 24 hours after injection, followed by warm
compresses if the inflammation persists

128. A mother brings her 4-month-old infant to the well baby clinic for immunizations. The
nurse would prepare to administer which of the following immunizations to this infant?
1. DTaP (diphtheria, tetanus, acellular pertussis), MMR (measles, mumps, rubella),
IPV(inactivated poliovirus vaccine)
2. MMR, Hib (Haemophilus influenzae type b), DtaP
3. DTaP, Hib, IPV
4. Varicella and hepatitis B vaccines

Answer: 4 Rationale: DTaP, Hib, IPV are administered at 4 months of age. DTaP is
administered at 2months, 4 months, 6 months, between 12 and 18 months, and between 4 and
6 years of age. Hibis administered at 2 months, 4 months, 6 months, and between 12 and 15
months of age. IPV isadministered at 2 months, 4 months, 6 months, and between 4 to 6 years
of age. The first dose of MMR is administered between 12 and 15 months of age; the second
dose is administered at 4 to6 years of age (if the second dose was not given by 4 to 6 years of
age, it should be given at thenext visit). The first dose of hepatitis B vaccine is administered
between the birth and 2 months,the second dose is administered between 1 and 4 months, and
the third dose is administered between 6 and 18 months of age. Varicella zoster vaccine is
administered between 12 and 18months of age

129. A client is complaining of skin irritation from the edges of a cast applied the previous day .
The nurse should plan for which of the following actions?

1. Massaging the skin at the rim of the cast

2. Applying lotion to the skin at the rim of the cast
3. Using a rough file to smooth the cast edges
4. Petaling the cast edges with adhesive tape

Answer: 4 Rationale: The edges of the cast can be petaled with tape to minimize skin
irritation. If a client has a cast applied and returns home, the client can be taught to do the
same

130.A client being measured for crutches asks the nurse why the crutches cannot rest up
underneath the arm for extra support. The nurse’s response is based on the understanding that
this could result in:
1. Impaired range of motion while the client ambulates
2. Skin breakdown in the area of the axilla
3. Injury to the brachial plexus nerves
4. A fall and further injury

Answer: 3 Rationale: Crutches are measured so that the tops are three or four fingerbreadths
or 1 to 2inches from the axilla. This ensures that the client’s axilla are not resting on the crutch
or bearing the weight of the crutch. This could result in injury to the nerves of the brachial
plexus

131.A nurse is planning to reinforce instructions to the client about how to stand on crutches.
In the written instructions, the nurse plans to tell the client to place the crutches:

1. 3 inches to the front and side of the client’s toes

2. 8 inches to the front and side of the client’s toes
3. 20 inches to the front and side of the client’s toes
4. 15 inches to the front and side of the client’s toes

Answer: 2 Rationale: The classic tripod position is taught to the client before giving
instructions on gait. The crutches are placed anywhere from 6 to 10 inches in front and to the
side of the client, depending on the client’s body size. This provides a wide enough base of
support to the client and improves balance.

132. A nurse is giving the client with a left leg cast crutch-walking instructions using the
three- point gait. The client is allowed touch-down of the affected leg. The nurse tells the client
to advance the:

1. Left leg and right crutch, then right leg and left crutch
2. Crutches and then both legs simultaneously
3. Crutches and the right leg, then advance the left leg
4. Crutches and the left leg, then advance the right leg

Answer: 4 Rationale: A three-point gait requires good balance and arm strength. The crutches
are advanced with the affected leg, and then the unaffected leg is moved forward. Option 1
describes a two- point gait. Option 2 describes a swing-to gait. Option 3 describes the three-
point gait used for aright leg problem

133. A nurse reinforces instructions to the parents of a child with leukemia regarding measures
related to monitoring for infection. Which statement by the parents indicates a need for
further instructions?

1. “I need to use proper hand washing techniques.”

2. “I need to take a rectal temperature daily on my child.”
3. “I need to inspect my child’s skin daily for redness.”
4. “I need to inspect my child’s mouth daily for lesions.”

Answer: 2 Rationale: The risk of injury to fragile mucous membranes is so great in the child
with leukemia that only oral, axillary, or tympanic temperatures should be taken. Rectal
abscesses can easily occur in damaged rectal tissue. No rectal temperatures should be taken.
Additionally, oral temperatures should be avoided if the child has oral ulcers. Options 1, 3, and
4 are appropriate teaching measures

134. A nurse is providing home care instructions to an adolescent who has been diagnosed with
tinea pedis. Which statement by the adolescent indicates a need for further instruction?

1. “I need to dry my feet carefully, especially between the toes.”

2. “I need to wear clean socks.”
3. “I need to wear shoes that are well ventilated.”
4. “I should wear plastic shoes as much as possible.”

Answer: 4 Rationale: Plastic shoes retain heat and should be avoided because this condition is
aggravated by heat and moisture. Options 1, 2, and 3 are appropriate measures to treat this
condition.

135. Griseofulvin (Fulvicin, Grisactin) is prescribed for a child with tinea capitis and the
nurse provides instructions to the mother regarding administration of the medication. Which
statement by the mother indicates a need for further instructions?
1. “I need to administer the medication 2 hours before meals.”
2. “I need to shake the oral suspension before preparing the dose.”
3. “I need to continue the therapy as long as it is prescribed.”
4. “I need to keep my child out of the sun.”

Answer: 1 Rationale: Griseofulvin is given with or after meals to avoid gastrointestinal (GI)
irritation andincrease absorption. Oral suspensions should be shaken well. Parents are
instructed to continue therapy as prescribed and not to miss a dose. Exposure to the sun is
avoided during treatment

136. A nurse prepares a list of home care instructions for the parents of school children
diagnosed with pediculosis (head lice). Which of the following is included in the list?

1. Use antilice sprays on all bedding and furniture

2. Take all bedding and linens to the cleaners to be dry cleaned
3. Boil combs and brushes in hot water for 2 hours
4. Vacuum floors, play areas, and furniture to remove any hairs that might carry live nits

Answer: 4 Rationale: Antilice sprays are unnecessary. Additionally, they should never be used
on a child. Bedding and linens should be washed with hot water and dried on a hot setting.
Items that cannot be washed should be dry cleaned or sealed in plastic bags in a warm place
for 3 weeks. Combs and brushes should be boiled or soaked in antilice shampoo or hot water
for 15 minutes. Thorough home cleaning is necessary to remove any remaining lice or nits.

137. A nurse provides instructions to the mother of a child with impetigo regarding the
application of antibiotic ointment and the mother asks the nurse when the child can return to
school. The nurse tells the mother that the child can return to school:

1. Twenty-four hours after using antibiotic ointment

2. Forty-eight hours after using antibiotic ointment
3. One week after using antibiotic ointment
4. Ten days after using antibiotic ointment

Answer: 2 Rationale: The child should not attend school for 24 to 48 hours after the initiation
of systemic antibiotics or 48 hours after using antibiotic ointment. The school should be notified
of the diagnosis. Therefore, options 1, 3, and 4 are incorrect.
138. The clinic nurse prepares to administer an MMR (measles, mumps, rubella) vaccine to a 5-
year-old child. The nurse administers this vaccine:

1. Intramuscularly in the anterolateral aspect of the thigh

2. Intramuscularly in the deltoid muscle
3. Subcutaneously in the outer aspect of the upper arm
4. Subcutaneously in the gluteal muscle

Answer: 3 Rationale: MMR vaccine is administered subcutaneously in the outer aspect of the
upper arm.The gluteal muscle is most often used for intramuscular injections. MMR vaccine is
notadministered by the intramuscular rout Permethrin 5% (Elimite) is prescribed for a 4-year-
old child with a diagnosis of scabies.

139.The nurse instructs the mother regarding the use of this treatment and tells the mother
to:1. Apply the lotion in the hair and on the face and entire body2. Apply the lotion and leave it
on for 4 hours3. Apply the lotion to cool dry skin at least ½ hour after bathing4. The child
should wear no clothing while the lotion is in placeAnswer: 3Rationale: Permethrin is applied
from the neck downward, making sure that the soles of the feet, behind the ears, and under
the toenails and fingernails are covered. The lotion should be kept onfor 8 to 14 hours, and
then the child should be given a bath. The lotion should not be applied for at least 30 minutes
after bathing and should be applied only to cool, dry skin. The child should be clothed during
treatment

140. A client has slight weakness in the right leg. Based on this data, the nurse determines that
the client would benefit most from the use of a:

1. Walker
 2. Wooden crutch
3. Lofstrand crutch
4. Straight-leg cane

Answer: 4 Rationale: A straight-leg cane is useful for the client with slight weakness in one
leg. A walker is beneficial to the client with greater or bilateral weakness or who is at risk for
falls. Wooden crutches are often used by clients with a leg cast. Lofstrand crutches aid clients
who need crutches, but have limited arm strength.

141.A client with right-sided weakness needs to learn how to use a cane. The nurse plans to
teach the client to position the cane by holding it with the:

1. Left hand, and placing the cane in front of the left foot
2. Right hand, and placing the cane in front of the right foot
3. Left hand, and 6 inches lateral to the left foot
4. Right hand, and 6 inches lateral to the right foot
Answer: 3 Rationale: The client is taught to hold the cane on the opposite side of the
weakness. This is done because, with normal walking, the opposite arm and leg move together
(called reciprocal motion). The cane is placed 6 inches lateral to the fifth toe

142. A client who is learning to use a cane is afraid it will slip with ambulation, causing a fall.
The nurse provides the client with the greatest reassurance by telling the client that:

1. Canes prevent falls, not cause them.

2. The cane has a flared tip with concentric rings to provide stability.
3. The physical therapist will determine if the cane is inadequate.
4. The cane would help to break a fall, even if the client does slip.

Answer: 2 Rationale: A cane should have a slightly flared tip, with flexible concentric rings.
This tip acts as a shock absorber and provides optimal stability. Options 1, 3, and 4 are not
incorrect

143. A nurse is evaluating the client’s use of a cane for left-sided weakness. The nurse would
intervene and correct the client if the nurse observed that the client:

1. Holds the cane on the right side

2. Keeps the cane 6 inches out to the side of the right foot
3. Moves the cane when the right leg is moved
4. Leans on the cane when the right leg swings through

Answer: 3 Rationale: The cane is held on the stronger side to minimize stress on the affected
extremity and provide a wide base of support. The cane is held 6 inches lateral to the fifth great
toe. The cane is moved forward with the affected leg. The client leans on the cane for added
support while the stronger side swings through

144. Nurse is caring for the client who has developed compartment syndrome from a severely
fractured arm. The client asks the nurse how this can happen. The nurse’s response is based on
the understanding that:

1. An injured artery causes impaired arterial perfusion through the compartment.

2. The fascia expands with injury, causing pressure on underlying nerves and muscles.
3. A bone fragment has injured the nerve supply in the area.
4. Bleeding and swelling cause increased pressure in an area that cannot expand.

Answer: 4 Rationale: Compartment syndrome is caused by bleeding and swelling within a

compartment lined by fascia, which does not expand. The bleeding and swelling places pressure
on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms.
145. A nurse is monitoring a confused older client admitted to the hospital with a hip fracture.
Which of the following data obtained by the nurse would not place the client at increased risk
for disturbed thought processes?

1. Stress induced by the fracture

2. Hearing aid available and in working order 
3. Unfamiliar hospital setting
4. Eyeglasses left at home

Answer: 2 Rationale: Confusion in the older client with hip fracture could result from the
unfamiliar hospital setting, stress from the fracture, concurrent systemic diseases, cerebral
ischemia, or side effects of medications. Use of eyeglasses and hearing aids enhances the
client’s interaction with the environment, and can reduce disorientation

146. A nurse is caring for an older client who had a hip pinned after being fractured. In
planning nursing care, which of the following would the nurse avoid to minimize the chance for
further injury?

1. Side rails in the “up” position

2. Use of night-light in hospital room and bathroom
3. Call bell placed within reach
4. Delays in responding to call light

Answer: 4 Rationale: Safe nursing actions intended to prevent injury to the client include
keeping side rails up, having the bed in a low position, and providing a call bell that is within
the client’s reach. Responding promptly to the client’s use of the call light minimizes the chance
that the client will try to get up alone, which could result in a fall

147.A nurse is repositioning the client who has returned to the nursing unit following internal
fixation of a fractured right hip. The nurse plans to use a:
1. Pillow to keep the right leg abducted during turning
2. Pillow to keep the right leg adducted during turning
3. Trochanter roll to prevent external rotation while turning
4. Trochanter roll to prevent abduction while turning

Answer: 1Rationale: Following internal fixation of a hip fracture, the client is turned to the
affected side or the unaffected side, as prescribed by the surgeon. Before moving the client, the
nurse places a pillow between the client’s legs to keep the affected leg in abduction. The client
is then repositioned while proper alignment and abduction are maintained. A trochanter roll is
useful in preventing external rotation, but it is used once the client has been repositioned. It is
not used while turning the client.

148. A client who has had a right total knee replacement asks the nurse how long the right leg
must be kept in the continuous passive motion (CPM) machine. The nurse’s response is based
on the understanding that the device should be used:1. For 30 minutes out of every hour 2.
Every other hour for 60 minutes3. For 3 hours at a time, followed by 1 hour of rest4. As much
as the client can tolerate

Answer: 4 Rationale: The client who has received a total knee replacement often has the leg
put into a CPM machine while in the postanesthesia care unit. The device increases circulation
and movement of the knee joint. It should be used as much as the client can tolerate

149. A nurse has an order to get the client out of bed to a chair on the first postoperative day
after total knee replacement. The nurse plans to do which of the following to protect the knee
joint?

1. Apply a knee immobilizer before getting the client up, and elevate the client’s surgical leg
while sitting.
2. Apply an ace wrap around the dressing, and put ice on the knee while sitting.
3. Lift the client to the bedside chair, leaving the continuous passive motion (CPM) machine
in place.
4. Obtain a walker to minimize weight-bearing by the client on the affected leg.

Answer: 1 Rationale: The nurse assists the client to get out of bed on the first postoperative
day after  putting a knee immobilizer on the affected joint for stability. The surgeon orders the
weight- bearing limits on the affected leg. The leg is elevated while the client is sitting in the
chair to minimize edema

150. A client with diabetes mellitus has had a right below-knee amputation. The nurse would be
especially vigilant in monitoring for which of the following because of the client’s history
of diabetes mellitus?

1. Edema of the stump

2. Hemorrhage
3. Separation of wound edges
4. Slight redness of incision

Answer: 3 Rationale: Clients with diabetes mellitus are more prone to wound infection and
delayed wound healing due to the disease. Postoperative stump edema and hemorrhage are
complications in the immediate postoperative period that apply to any client with an
amputation. Slight redness of the incision is considered normal, as long it is dry and intac.

151. A client is admitted to the nursing unit after a left below-knee amputation following a
crush injury to the foot and lower leg. The client tells the nurse “I think I’m going crazy. I can
feel my left foot itching.” The nurse interprets the client’s statement to be:

1. A normal response, and indicates the presence of phantom limb sensation

2. A normal response, and indicates the presence of phantom limb pain
3. An abnormal response, and indicates that the client needs more psychological support
4. An abnormal response, and indicates that the client is in denial about the limb loss

Answer: 1 Rationale: Phantom limb sensations are felt in the area of the amputated limb.
These can include itching, warmth, and cold. The sensations are caused by intact peripheral
nerves in the area amputated. Whenever possible, clients should be prepared for these
sensations. The client may also feel painful sensations in the amputated limb, called phantom
limb pain. The origin of the pain is less well understood, but the client should also be prepared
for this, whenever possible.

152. A client is complaining of low back pain, with radiation down the left posterior thigh. The
nurse continues to collect data from the client to see if the pain is worsened or aggravated by:

1. Bed rest
2. Application of heat
3. Bending or lifting
4. Ibuprofen (Motrin)

Answer: 3Rationale: Low back pain with radiation into one leg (sciatica) is consistent with
herniatedlumbar disk. The nurse continues to collect data from the client to see if the pain is
aggravated by events that increase intraspinal pressure, such as bending, lifting, sneezing,
coughing or lifting the leg straight up while supine (straight leg raising test). Options 1, 2, and 4
assist in alleviating pain

153. A client has just undergone spinal fusion after suffering a herniated lumbar disk. The nurse
would avoid which of the following to maintain client safety after this procedure?

1. Logrolling technique for repositioning

2. Pillows under the length of the legs
3. Head of bed flat
4. Overhead trapeze

Answer: 4 Rationale: Following spinal fusion, the head of bed is generally kept in a flat
position. The client is logrolled from side to side as ordered. Pillows may be placed under the
entire length of the legs by surgeon preference to relieve tension on the lower back. The use of
an overhead trapeze is contraindicated because its use could promote twisting of the spine after
surgery

154. A nurse has reinforced instructions with a client with a herniated lumbar disk about
proper  body mechanics and other items pertinent to low back care. The nurse determines that
the client needs further instructions if the client verbalizes that he or she will:

1. Get out of bed by sitting straight up and swinging legs over the side of the bed.
2. Increase fiber and fluids in the diet.
3. Strengthen the back muscles by swimming or walking.
4. Bend at the knees to pick up objects.

Answer: 1Rationale: Clients are taught to get out of bed by sliding near to the edge of the
mattress. The client then rolls onto one side and pushes up from the bed using one or both
arms. The back is kept straight and the legs are swung over the side. Increasing fluids and
dietary fiber helps prevent straining at stool, thereby preventing increases in intraspinal
pressure. Walking and swimming are excellent exercises for strengthening lower back muscles.
Proper body mechanics includes bending at the knees, not the waist, to lift object

155. A client who has had spinal fusion and insertion of hardware is extremely concerned
about the perceived lengthy rehabilitation period. The client expresses concerns about finances
and ability to return to prior employment. The nurse understands that the client’s needs could
best be addressed by referral to the:

1. Surgeon
2. Clinical nurse specialist
3. Social worker 
4. Physical therapist

Answer: 3 Rationale: Following spinal surgery, concerns about finances and employment are
best handled by referral to a social worker. This individual will provide information about
resources available to the client. The physical therapist has the best knowledge of techniques
for increasing mobility and endurance. The clinical nurse specialist and surgeon do not have
information related to financial resources

156. A nurse is planning to reinforce instructions to the client about proper use of
athoracolumbosacral orthosis (TLSO) after spinal fusion with instrumentation. The nurse plans
toinclude which of the following teaching points in discussion with the client?

1. Areas of skin redness at the edges of the brace indicates a good, snug fit.
2. The device is applied before getting out of bed in the morning.
3. The brace should be applied directly next to the skin.
4. The Velcro closures should be fairly loose to avoid constriction.

Answer: 2 Rationale: A back brace or thoracolumbosacral orthosis is individually fitted to the

client. The brace should not irritate the skin with proper fitting. The brace is applied in the
morning before getting out of bed. The closures should be secure, but not overly loose or tight.
A layer of clothing is worn between the orthosis and the skin

157. A client is complaining of pain underneath a cast in the area of a bony prominence. The
nurse interprets that this client may need to have:

1. The cast replaced with an air splint

2. Extra padding put over this area of the cast
3. The cast bivalve
4. A window cut in the cast

Answer: 4 Rationale: A window may be cut in a dried cast to relieve pressure, monitor pulses,
relieve discomfort, or remove drains. Bivalving the cast involves splitting the cast along both
sides to allow space for swelling, facilitate taking x-rays, or make a half-cast for use as an
intermittent splint. Padding is not placed on top of a cast. The use of an air splint is not
indicated

158. A client is fearful about having an arm cast removed. Which of the following actions by the
nurse would be the most helpful?

1. Telling the client that the saw makes a frightening noise

2. Reassuring the client that no one has had an arm lacerated yet
3. Stating that the hot cutting blades cause burns only very rarely
4. Showing the client the cast cutter and explaining how it works

Answer: 4 Rationale: Clients may be fearful of having a cast removed because of

misconceptions about the cast cutting blade. The nurse should show the cast cutter to the client
before it is used, and explain that the client may feel heat, vibration, and pressure. The cast
cutter resembles a small electric saw with a circular blade. The nurse should reassure the client
that the blade does not cut like a saw, but instead cuts the cast by vibrating side to side

159. A nursing instructor asks a nursing student about the risk factors associated with
osteoporosis. The instructor tells the student that she needs to read and learn about this
disorder if the student states that which of the following is an associated risk factor?

1. High-calcium diet consumption

2. Postmenopausal age
3. Long-term use of corticosteroids
4. Family history of osteoporosis

Answer: 1Rationale: Risk factors associated with osteoporosis include a diet that is deficient in
calcium. Options 2, 3, and 4 include risk factors associated with osteoporosis. Additional risk
factors include being sedentary, cigarette smoking, excessive alcohol consumption, chronic
illness, and long-term use of anticonvulsants and furosemide

160. Nurse is caring for a client with a diagnosis of gout. Which of the following laboratory
values would the nurse expect to note in the client?

1. Uric acid level of 8.0 mg/dL

2. Calcium level of 9.0 mg/dL
3. Phosphorus level of 3.0 mg/dL
4. Potassium level of 4.0 mEq/L
Answer: 1 Rationale: In addition to the presence of clinical manifestations, gout is diagnosed
by the presence of persistent hyperuricemia, with the uric acid level higher than 7 mg/dL.
Options 2, 3,and 4 all indicate normal laboratory values. Additionally, the presence of uric acid
in an aspirated sample of synovial fluid confirms the diagnosis

161. 6A nurse is caring for a client with osteoarthritis. The nurse collects data, knowing that
which of the following is a clinical manifestation associated with the disorder?

1. Pain that is most severe later in the day

2. An elevated platelet count
3. Dull aching pain in the affected joints
4. Elevated antinuclear antibody levels

Answer: 3 Rationale: The stiffness and joint pain that occur in osteoarthritis increase with lack
of activity, are usually more severe in the morning, and may be aggravated by cold, damp
weather. Nospecific laboratory findings are useful in diagnosing osteoarthritis. The client may
have a normal or slightly elevated sedimentation rate. Dull, aching pain occurs in the affected
joints and, unlike rheumatoid arthritis, systemic manifestations are absent and joint
involvement is not symmetrical. Elevated white blood cell counts, platelet counts, and
antinuclear antibodies occur in rheumatoid arthritis.

GOOLUCK RN’s.. God bless