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Part 2
Nursing Practice I-V Answers and Rationale
NURSING PRACTICE I
a. I.V
b. I.M
c. Oral
d. S.C
3. Dr. Garcia writes the following order for the client who has been
recently admitted “Digoxin .125 mg P.O. once daily.” To prevent a
dosage error, how should the nurse document this order onto the
medication administration record?
9. Tony, a basketball player twist his right ankle while playing on the court
and seeks care for ankle pain and swelling. After the nurse applies ice
to the ankle for 30 minutes, which statement by Tony suggests that ice
application has been effective?
a. Hypernatremia
b. Hyperkalemia
c. Hypokalemia
d. Hypervolemia
11. She finds out that some managers have benevolent-authoritative style of
management. Which of the following behaviors will she exhibit most
likely?
12. Nurse Amy is aware that the following is true about functional nursing
13. Which type of medication order might read "Vitamin K 10 mg I.M. daily ×
3 days?"
a. Single order
b. Standard written order
c. Standing order
d. Stat order
a. Increased appetite
b. Loss of urge to defecate
c. Hard, brown, formed stools
d. Liquid or semi-liquid stools
16. Which instruction should nurse Tom give to a male client who is
having external radiation therapy:
17. In assisting a female client for immediate surgery, the nurse In-charge
is aware that she should:
18. A male client is admitted and diagnosed with acute pancreatitis after a
holiday celebration of excessive food and alcohol. Which assessment
finding reflects this diagnosis?
19. Which dietary guidelines are important for nurse Oliver to implement
in caring for the client with burns?
21. Nurse Michelle witnesses a female client sustain a fall and suspects that
the leg may be broken. The nurse takes which priority action?
22. A male client is being transferred to the nursing unit for admission after
receiving a radium implant for bladder cancer. The nurse in-charge
would take which priority action in the care of this client?
a. Constipation
b. Diarrhea
c. Risk for infection
d. Deficient knowledge
a. Autocratic.
b. Laissez-faire.
26. The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. The
nurse in-charge is going to hang a 500 cc bag. KCl is supplied 20
mEq/10 cc. How many cc’s of KCl will be added to the IV solution?
a. .5 cc
b. 5 cc
c. 1.5 cc
d. 2.5 cc
a. 50 cc/ hour
b. 55 cc/ hour
c. 24 cc/ hour
d. 66 cc/ hour
28. The nurse is aware that the most important nursing action when a
client returns from surgery is:
31. Asking the questions to determine if the person understands the health
teaching provided by the nurse would be included during which step of
the nursing process?
a. Assessment
b. Evaluation
c. Implementation
d. Planning and goals
32. Which of the following item is considered the single most important
factor in assisting the health professional in arriving at a diagnosis or
determining the person’s needs?
34. Which stage of pressure ulcer development does the ulcer extend into
the subcutaneous tissue?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
35. When the method of wound healing is one in which wound edges are
not surgically approximated and integumentary continuity is restored by
granulations, the wound healing is termed
a. Hypothermia
b. Hypertension
c. Distended neck veins
d. Tachycardia
a. 0.75
b. 0.6
c. 0.5
d. 0.25
38. A male client with diabetes mellitus is receiving insulin. Which statement
correctly describes an insulin unit?
a. 40.1 °C
b. 38.9 °C
c. 48 °C
d. 38 °C
40. The nurse is assessing a 48-year-old client who has come to the
physician’s office for his annual physical exam. One of the first
physical signs of aging is:
41. The physician inserts a chest tube into a female client to treat a
pneumothorax. The tube is connected to water-seal drainage. The
nurse in-charge can prevent chest tube air leaks by:
42. Nurse Trish must verify the client’s identity before administering
medication. She is aware that the safest way to verify identity is
to:
a. Check the client’s identification band.
b. Ask the client to state his name.
c. State the client’s name out loud and wait a client to repeat it.
d. Check the room number and the client’s name on the bed.
a. 30 drops/minute
b. 32 drops/minute
c. 20 drops/minute
d. 18 drops/minute
45. A female client was recently admitted. She has fever, weight loss, and
watery diarrhea is being admitted to the facility. While assessing the
client, Nurse Hazel inspects the client’s abdomen and notice that it is
slightly concave. Additional assessment should proceed in which order:
a. Fingertips
b. Finger pads
c. Dorsal surface of the hand
d. Ulnar surface of the hand
47. Which type of evaluation occurs continuously throughout the teaching and
learning process?
a. Summative
b. Informative
c. Formative
d. Retrospective
48. A 45 year old client, has no family history of breast cancer or other
risk factors for this disease. Nurse John should instruct her to have
mammogram how often?
49. A male client has the following arterial blood gas values: pH 7.30; Pao2
89 mmHg; Paco2 50 mmHg; and HCO3 26mEq/L. Based on these values,
Nurse Patricia should expect which condition?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis
50. Nurse Len refers a female client with terminal cancer to a local
hospice. What is the goal of this referral?
52. Nurse Oliver must apply an elastic bandage to a client’s ankle and calf.
He should apply the bandage beginning at the client’s:
a. Knee
b. Ankle
c. Lower thigh
d. Foot
53. A 10 year old child with type 1 diabetes develops diabetic ketoacidosis
and receives a continuous insulin infusion. Which condition represents
the greatest risk to this child?
a. Hypernatremia
b. Hypokalemia
c. Hyperphosphatemia
d. Hypercalcemia
55. Nurse Michelle hears the alarm sound on the telemetry monitor. The
nurse quickly looks at the monitor and notes that a client is in a ventricular
tachycardia. The nurse rushes to the client’s room. Upon reaching the
client’s bedside, the nurse would take which action first?
57. Nurse Janah is monitoring the ongoing care given to the potential
organ donor who has been diagnosed with brain death. The nurse
determines that the standard of care had been maintained if which of
the following data is observed?
58. Nurse Amy has an order to obtain a urinalysis from a male client with an
indwelling urinary catheter. The nurse avoids which of the following,
which contaminate the specimen?
a. Wiping the port with an alcohol swab before inserting the syringe.
b. Aspirating a sample from the port on the drainage bag.
c. Clamping the tubing of the drainage bag.
d. Obtaining the specimen from the urinary drainage bag.
59. Nurse Meredith is in the process of giving a client a bed bath. In the
middle of the procedure, the unit secretary calls the nurse on the
intercom to tell the nurse that there is an emergency phone call. The
appropriate nursing action is to:
60. Nurse Janah is collecting a sputum specimen for culture and sensitivity
testing from a client who has a productive cough. Nurse Janah plans to
implement which intervention to obtain the specimen?
61. Nurse Ron is observing a male client using a walker. The nurse
determines that the client is using the walker correctly if the
client:
a. Puts all the four points of the walker flat on the floor, puts weight
on the hand pieces, and then walks into it.
b. Puts weight on the hand pieces, moves the walker forward,
and then walks into it.
c. Puts weight on the hand pieces, slides the walker forward, and
then walks into it.
d. Walks into the walker, puts weight on the hand pieces, and
then puts all four points of the walker flat on the floor.
62. Nurse Amy has documented an entry regarding client care in the client’s
medical record. When checking the entry, the nurse realizes that
incorrect information was documented. How does the nurse correct this
error?
63. Nurse Ron is assisting with transferring a client from the operating
room table to a stretcher. To provide safety to the client, the nurse
should:
a. Crutches
b. Single straight-legged cane
c. Quad cane
d. Walker
66. A male client with a right pleural effusion noted on a chest X-ray is being
prepared for thoracentesis. The client experiences severe dizziness
when sitting upright. To provide a safe environment, the nurse assists the
client to which position for the procedure?
67. Nurse John develops methods for data gathering. Which of the following
criteria of a good instrument refers to the ability of the instrument to
yield the same results upon its repeated administration?
a. Validity
b. Specificity
c. Sensitivity
d. Reliability
68. Harry knows that he has to protect the rights of human research
subjects. Which of the following actions of Harry ensures anonymity?
a. Descriptive- correlational
b. Experiment
c. Quasi-experiment
d. Historical
a. Interview schedule
b. Questionnaire
c. Use of laboratory data
d. Observation
71. Monica is aware that there are times when only manipulation of study
variables is possible and the elements of control or randomization are
not attendant. Which type of research is referred to this?
a. Field study
b. Quasi-experiment
c. Solomon-Four group design
d. Post-test only design
72. Cherry notes down ideas that were derived from the description of
an investigation written by the person who conducted it. Which type
of reference source refers to this?
a. Footnote
b. Bibliography
c. Primary source
d. Endnotes
73. When Nurse Trish is providing care to his patient, she must remember
that her duty is bound not to do doing any action that will cause the patient
harm. This is the meaning of the bioethical principle:
a. Non-maleficence
b. Beneficence
c. Justice
d. Solidarity
74. When a nurse in-charge causes an injury to a female patient and the
injury caused becomes the proof of the negligent act, the presence of the
injury is said to exemplify the principle of:
a. Force majeure
b. Respondeat superior
c. Res ipsa loquitor
d. Holdover doctrine
a. The Board can issue rules and regulations that will govern
the practice of nursing
b. The Board can investigate violations of the nursing law and code
of ethics
c. The Board can visit a school applying for a permit in
collaboration with CHED
d. The Board prepares the board examinations
76. When the license of nurse Krina is revoked, it means that she:
a. Is no longer allowed to practice the profession for the rest of her life
b. Will never have her/his license re-issued since it has been revoked
c. May apply for re-issuance of his/her license based on
certain conditions stipulated in RA 9173
d. Will remain unable to practice professional nursing
78. The leader of the study knows that certain patients who are in a
specialized research setting tend to respond psychologically to
the conditions of the study. This referred to as :
79. Mary finally decides to use judgment sampling on her research. Which
of the following actions of is correct?
80. The nursing theorist who developed transcultural nursing theory is:
a. Florence Nightingale
b. Madeleine Leininger
c. Albert Moore
d. Sr. Callista Roy
81. Marion is aware that the sampling method that gives equal chance to
all units in the population to get picked is:
a. Random
b. Accidental
c. Quota
d. Judgment
82. John plans to use a Likert Scale to his study to determine the:
83. Which of the following theory addresses the four modes of adaptation?
a. Madeleine Leininger
b. Sr. Callista Roy
c. Florence Nightingale
d. Jean Watson
a. Span of control
b. Unity of command
c. Downward communication
d. Leader
a. Beneficence
b. Autonomy
c. Veracity
d. Non-maleficence
a. Lithotomy
b. Supine
c. Prone
d. Sims’ left lateral
90. A 65 years old male client requests his medication at 9 p.m. instead of 10
p.m. so that he can go to sleep earlier. Which type of nursing intervention
is required?
a. Independent
b. Dependent
c. Interdependent
d. Intradependent
92. Nursing care for a female client includes removing elastic stockings
once per day. The Nurse Betty is aware that the rationale for this
intervention?
93. Which nursing intervention takes highest priority when caring for a
newly admitted client who's receiving a blood transfusion?
a. Do nothing.
b. Invert the vial and let it stand for 3 to 5 minutes.
c. Shake the vial vigorously.
d. Roll the vial gently between the palms.
96. Which intervention should the nurse Trish use when administering
oxygen by face mask to a female client?
97. The maximum transfusion time for a unit of packed red blood cells
(RBCs) is:
a. 6 hours
b. 4 hours
c. 3 hours
d. 2 hours
99. Nurse May is aware that the main advantage of using a floor stock
system is:
1. May arrives at the health care clinic and tells the nurse that her last
menstrual period was 9 weeks ago. She also tells the nurse that a home
pregnancy test was positive but she began to have mild cramps and is
now having moderate vaginal bleeding. During the physical examination of
the client, the nurse notes that May has a dilated cervix. The nurse
determines that May is experiencing which type of abortion?
a. Inevitable
b. Incomplete
c. Threatened
d. Septic
2. Nurse Reese is reviewing the record of a pregnant client for her first
prenatal visit. Which of the following data, if noted on the client’s record,
would alert the nurse that the client is at risk for a spontaneous
abortion?
a. Age 36 years
b. History of syphilis
c. History of genital herpes
d. History of diabetes mellitus
a. Monitoring weight
b. Assessing for edema
c. Monitoring apical pulse
d. Monitoring temperature
a. Ventilator assistance
b. CVP readings
c. EKG tracings
d. Continuous CPR
11. Nurse Ryan is aware that the best initial approach when trying to take
a crying toddler’s temperature is:
12. Baby Tina a 3 month old infant just had a cleft lip and palate repair.
What should the nurse do to prevent trauma to operative site?
13. Which action should nurse Marian include in the care plan for a 2
month old with heart failure?
15. Mommy Linda is playing with her infant, who is sitting securely alone
on the floor of the clinic. The mother hides a toy behind her back and
the
Nursing Crib – Student Nurses’ Community 29
infant looks for it. The nurse is aware that estimated age of the infant
would be:
a. 6 months
b. 4 months
c. 8 months
d. 10 months
a. Effectiveness
b. Efficiency
c. Adequacy
d. Appropriateness
a. Department of Health
b. Provincial Health Office
c. Regional Health Office
d. Rural Health Unit
19. Tony is aware the Chairman of the Municipal Health Board is:
a. Mayor
b. Municipal Health Officer
c. Public Health Nurse
d. Any qualified physician
20. Myra is the public health nurse in a municipality with a total population
of about 20,000. There are 3 rural health midwives among the RHU
personnel. How many more midwife items will the RHU need?
a. Poliomyelitis
b. Measles
c. Rabies
d. Neonatal tetanus
23. May knows that the step in community organizing that involves training
of potential leaders in the community is:
a. Integration
b. Community organization
c. Community study
d. Core group formation
a. Pre-pathogenesis
b. Pathogenesis
c. Prodromal
d. Terminal
26. The nurse is caring for a primigravid client in the labor and delivery
area. Which condition would place the client at risk for disseminated
intravascular coagulation (DIC)?
27.A A fullterm client is in labor. Nurse Betty is aware that the fetal heart
rate would be:
a. 80 to 100 beats/minute
b. 100 to 120 beats/minute
c. 120 to 160 beats/minute
d. 160 to 180 beats/minute
28. The skin in the diaper area of a 7 month old infant is excoriated and
red. Nurse Hazel should instruct the mother to:
29. Nurse Carla knows that the common cardiac anomalies in children
with Down Syndrome (tri-somy 21) is:
a. Anemia
31.A A 23 year old client is having her menstrual period every 2 weeks that
last for 1 week. This type of menstrual pattern is bets defined by:
a. Menorrhagia
b. Metrorrhagia
c. Dyspareunia
d. Amenorrhea
32. Jannah is admitted to the labor and delivery unit. The critical
laboratory result for this client would be:
a. Oxygen saturation
b. Iron binding capacity
c. Blood typing
d. Serum Calcium
33. Nurse Gina is aware that the most common condition found during
the second-trimester of pregnancy is:
a. Metabolic alkalosis
b. Respiratory acidosis
c. Mastitis
d. Physiologic anemia
35. Maureen in her third trimester arrives at the emergency room with
painless vaginal bleeding. Which of the following conditions is suspected?
a. Placenta previa
b. Abruptio placentae
c. Premature labor
d. Sexually transmitted disease
a. “I should check the diaphragm carefully for holes every time I use it”
b. “I may need a different size of diaphragm if I gain or lose
weight more than 20 pounds”
c. “The diaphragm must be left in place for atleast 6 hours
after intercourse”
d. “I really need to use the diaphragm and jelly most during the
middle of my menstrual cycle”.
a. Drooling
b. Muffled voice
c. Restlessness
d. Low-grade fever
40. How should Nurse Michelle guide a child who is blind to walk to
the playroom?
42. The reason nurse May keeps the neonate in a neutral thermal
environment is that when a newborn becomes too cool, the
neonate requires:
43. Before adding potassium to an infant’s I.V. line, Nurse Ron must be
sure to assess whether this infant has:
44. Nurse Carla should know that the most common causative factor of
dermatitis in infants and younger children is:
a. Baby oil
b. Baby lotion
c. Laundry detergent
d. Powder with cornstarch
45. During tube feeding, how far above an infant’s stomach should the
nurse hold the syringe with formula?
a. 6 inches
b. 12 inches
c. 18 inches
d. 24 inches
48. Myrna a public health nurse knows that to determine possible sources of
sexually transmitted infections, the BEST method that may be
undertaken is:
a. Contact tracing
b. Community survey
c. Mass screening tests
d. Interview of suspects
49.A A 33-year old female client came for consultation at the health center
with the chief complaint of fever for a week. Accompanying symptoms
were muscle pains and body malaise. A week after the start of fever, the
client noted yellowish discoloration of his sclera. History showed that he
waded in flood waters about 2 weeks before the onset of symptoms.
Based on her history, which disease condition will you suspect?
a. Hepatitis A
b. Hepatitis B
c. Tetanus
d. Leptospirosis
50. Mickey a 3-year old client was brought to the health center with the
chief complaint of severe diarrhea and the passage of “rice water”
stools. The client is most probably suffering from which condition?
a. Giardiasis
b. Cholera
c. Amebiasis
51. The most prevalent form of meningitis among children aged 2 months to
3 years is caused by which microorganism?
a. Hemophilus influenzae
b. Morbillivirus
c. Steptococcus pneumoniae
d. Neisseria meningitidis
52. The student nurse is aware that the pathognomonic sign of measles
is Koplik’s spot and you may see Koplik’s spot by inspecting the:
a. Nasal mucosa
b. Buccal mucosa
c. Skin on the abdomen
d. Skin on neck
53. Angel was diagnosed as having Dengue fever. You will say that there is
slow capillary refill when the color of the nailbed that you pressed does
not return within how many seconds?
a. 3 seconds
b. 6 seconds
c. 9 seconds
d. 10 seconds
a. Mastoiditis
b. Severe dehydration
c. Severe pneumonia
d. Severe febrile disease
a. 45 infants
b. 50 infants
c. 55 infants
d. 65 infants
a. DPT
b. Oral polio vaccine
c. Measles vaccine
d. MMR
a. Use of molluscicides
b. Building of foot bridges
c. Proper use of sanitary toilets
d. Use of protective footwear, such as rubber boots
58. Several clients is newly admitted and diagnosed with leprosy. Which of
the following clients should be classified as a case of multibacillary
leprosy?
a. Macular lesions
b. Inability to close eyelids
c. Thickened painful nerves
d. Sinking of the nosebridge
60. Marie brought her 10 month old infant for consultation because of fever,
started 4 days prior to consultation. In determining malaria risk, what
will you do?
61. Susie brought her 4 years old daughter to the RHU because of cough
and colds. Following the IMCI assessment guide, which of the following is
a danger sign that indicates the need for urgent referral to a hospital?
62. Jimmy a 2-year old child revealed “baggy pants”. As a nurse, using
the IMCI guidelines, how will you manage Jimmy?
63. Gina is using Oresol in the management of diarrhea of her 3-year old
child. She asked you what to do if her child vomits. As a nurse you will
tell her to:
64. Nikki a 5-month old infant was brought by his mother to the health center
because of diarrhea for 4 to 5 times a day. Her skin goes back slowly
after a skin pinch and her eyes are sunken. Using the IMCI guidelines,
you will classify this infant in which category?
a. No signs of dehydration
b. Some dehydration
c. Severe dehydration
d. The data is insufficient.
65. Chris a 4-month old infant was brought by her mother to the health
center because of cough. His respiratory rate is 42/minute. Using the
Integrated Management of Child Illness (IMCI) guidelines of assessment,
his breathing is considered as:
a. Fast
b. Slow
c. Normal
d. Insignificant
a. 1 year
b. 3 years
c. 5 years
d. Lifetime
67. Nurse Ron is aware that unused BCG should be discarded after
how many hours of reconstitution?
a. 2 hours
b. 4 hours
c. 8 hours
d. At the end of the day
a. 5 months
b. 6 months
c. 1 year
d. 2 years
69. Nurse Ron is aware that the gestational age of a conceptus that
is considered viable (able to live outside the womb) is:
a. 8 weeks
b. 12 weeks
c. 24 weeks
d. 32 weeks
70. When teaching parents of a neonate the proper position for the
neonate’s sleep, the nurse Patricia stresses the importance of placing
the neonate on his back to reduce the risk of which of the following?
a. Aspiration
b. Sudden infant death syndrome (SIDS)
c. Suffocation
d. Gastroesophageal reflux (GER)
a. Flushed cheeks
b. Increased temperature
73. Marjorie has just given birth at 42 weeks’ gestation. When the
nurse assessing the neonate, which physical finding is expected?
a. Hypoglycemia
b. Jitteriness
c. Respiratory depression
d. Tachycardia
a. Nasal flaring
b. Light audible grunting
c. Respiratory rate 40 to 60 breaths/minute
d. Respiratory rate 60 to 80 breaths/minute
76. When teaching umbilical cord care for Jennifer a new mother, the
nurse Jenny would include which information?
82.A A neonate begins to gag and turns a dusky color. What should the
nurse do first?
83.When a client states that her "water broke," which of the following
actions would be inappropriate for the nurse to do?
84. A baby girl is born 8 weeks premature. At birth, she has no spontaneous
respirations but is successfully resuscitated. Within several hours she develops
respiratory grunting, cyanosis, tachypnea, nasal flaring, and retractions. She's
diagnosed with respiratory distress syndrome, intubated, and placed on a
ventilator. Which nursing action should be included in the baby's plan of care
to prevent retinopathy of prematurity?
86. Nurse John is knowledgeable that usually individual twins will grow
appropriately and at the same rate as singletons until how many
weeks?
a. 16 to 18 weeks
b. 18 to 22 weeks
c. 30 to 32 weeks
d. 38 to 40 weeks
a. conjoined twins
b. diamniotic dichorionic twins
Nursing Crib – Student Nurses’ Community 43
c. diamniotic monochorionic twin
d. monoamniotic monochorionic twins
88. Tyra experienced painless vaginal bleeding has just been diagnosed as
having a placenta previa. Which of the following procedures is usually
performed to diagnose placenta previa?
a. Amniocentesis
b. Digital or speculum examination
c. External fetal monitoring
d. Ultrasound
a. Diet
b. Long-acting insulin
c. Oral hypoglycemic
d. Oral hypoglycemic drug and insulin
a. Hemorrhage
b. Hypertension
c. Hypomagnesemia
d. Seizure
92. Cammile with sickle cell anemia has an increased risk for having a sickle
cell crisis during pregnancy. Aggressive management of a sickle cell crisis
includes which of the following measures?
a. Antihypertensive agents
b. Diuretic agents
c. I.V. fluids
d. Acetaminophen (Tylenol) for pain
94. Marlyn is screened for tuberculosis during her first prenatal visit. An
intradermal injection of purified protein derivative (PPD) of the tuberculin bacilli is
given. She is considered to have a positive test for which of the following
results?
a. Asymptomatic bacteriuria
b. Bacterial vaginosis
c. Pyelonephritis
d. Urinary tract infection (UTI)
97. To promote comfort during labor, the nurse John advises a client to
assume certain positions and avoid others. Which position may cause maternal
hypotension and fetal hypoxia?
a. Lateral position
b. Squatting position
c. Supine position
Nursing Crib – Student Nurses’ Community 45
d. Standing position
98. Celeste who used heroin during her pregnancy delivers a neonate. When
assessing the neonate, the nurse Lhynnette expects to find:
99. The uterus returns to the pelvic cavity in which of the following time frames?
100. Maureen, a primigravida client, age 20, has just completed a difficult,
forceps-assisted delivery of twins. Her labor was unusually long and required
oxytocin (Pitocin) augmentation. The nurse who's caring for her should stay
alert for:
a. Uterine inversion
b. Uterine atony
c. Uterine involution
d. Uterine discomfort
1. Nurse Michelle should know that the drainage is normal 4 days after
a sigmoid colostomy when the stool is:
a. Green liquid
b. Solid formed
c. Loose, bloody
d. Semiformed
2. Where would nurse Kristine place the call light for a male client with a
right-sided brain attack and left homonymous hemianopsia?
12. A male client has active tuberculosis (TB). Which of the following
symptoms will be exhibit?
a. Acute asthma
b. Bronchial pneumonia
c. Chronic obstructive pulmonary disease (COPD)
d. Emphysema
14. Marichu was given morphine sulfate for pain. She is sleeping and her
respiratory rate is 4 breaths/minute. If action isn’t taken quickly, she might
have which of the following reactions?
a. Asthma attack
b. Respiratory arrest
c. Seizure
d. Wake up on his own
16. Nurse John is caring for a male client receiving lidocaine I.V. Which factor
is the most relevant to administration of this medication?
17. Nurse Ron is caring for a male client taking an anticoagulant. The
nurse should teach the client to:
18. Nurse Lhynnette is preparing a site for the insertion of an I.V. catheter.
The nurse should treat excess hair at the site by:
19. Nurse Michelle is caring for an elderly female with osteoporosis. When
teaching the client, the nurse should include information about which
major complication:
a. Bone fracture
b. Loss of estrogen
c. Negative calcium balance
d. Dowager’s hump
20. Nurse Len is teaching a group of women to perform BSE. The nurse
should explain that the purpose of performing the examination is to discover:
a. Cancerous lumps
b. Areas of thickness or fullness
c. Changes from previous examinations.
d. Fibrocystic masses
21. When caring for a female client who is being treated for hyperthyroidism, it
is important to:
23. Nurse Greta is working on a surgical floor. Nurse Greta must logroll a
client following a:
a. Laminectomy
b. Thoracotomy
c. Hemorrhoidectomy
d. Cystectomy.
24. A 55-year old client underwent cataract removal with intraocular lens
implant. Nurse Oliver is giving the client discharge instructions. These
instructions should include which of the following?
27. Nurse Audrey is caring for a client who has suffered a severe
cerebrovascular accident. During routine assessment, the nurse notices
Cheyne- Strokes respirations. Cheyne-strokes respirations are:
28. Nurse Bea is assessing a male client with heart failure. The breath
sounds commonly auscultated in clients with heart failure are:
a. Tracheal
b. Fine crackles
c. Coarse crackles
d. Friction rubs
29. The nurse is caring for Kenneth experiencing an acute asthma attack.
The client stops wheezing and breath sounds aren’t audible. The reason for
this change is that:
30. Mike with epilepsy is having a seizure. During the active seizure phase,
the nurse should:
a. Place the client on his back remove dangerous objects, and insert
a bite block.
b. Place the client on his side, remove dangerous objects, and insert
a bite block.
c. Place the client o his back, remove dangerous objects, and hold
down his arms.
d. Place the client on his side, remove dangerous objects, and protect
his head.
32. Nurse Maureen is talking to a male client, the client begins choking on
his lunch. He’s coughing forcefully. The nurse should:
34. When performing oral care on a comatose client, Nurse Krina should:
36. Nurse Oliver is working in a out patient clinic. He has been alerted that
there is an outbreak of tuberculosis (TB). Which of the following clients entering
the clinic today most likely to have TB?
37. Virgie with a positive Mantoux test result will be sent for a chest X-ray.
The nurse is aware that which of the following reasons this is done?
38. Kennedy with acute asthma showing inspiratory and expiratory wheezes
and a decreased forced expiratory volume should be treated with which of the
following classes of medication right away?
a. Beta-adrenergic blockers
b. Bronchodilators
c. Inhaled steroids
d. Oral steroids
39. Mr. Vasquez 56-year-old client with a 40-year history of smoking one to
two packs of cigarettes per day has a chronic cough producing thick sputum,
peripheral edema and cyanotic nail beds. Based on this information, he most
likely has which of the following conditions?
42. During routine care, Francis asks the nurse, “How can I be anemic if this
disease causes increased my white blood cell production?” The nurse in-charge
best response would be that the increased number of white blood cells (WBC)
is:
Nursing Crib – Student Nurses’ Community 55
a. Crowd red blood cells
b. Are not responsible for the anemia.
c. Uses nutrients from other cells
d. Have an abnormally short life span of cells.
a. Predominance of lymhoblasts
b. Leukocytosis
c. Abnormal blast cells in the bone marrow
d. Elevated thrombocyte counts
44. Robert, a 57-year-old client with acute arterial occlusion of the left leg
undergoes an emergency embolectomy. Six hours later, the nurse isn’t able to
obtain pulses in his left foot using Doppler ultrasound. The nurse immediately
notifies the physician, and asks her to prepare the client for surgery. As the
nurse enters the client’s room to prepare him, he states that he won’t have any
more surgery. Which of the following is the best initial response by the nurse?
45. During the endorsement, which of the following clients should the on-
duty nurse assess first?
a. The 58-year-old client who was admitted 2 days ago with heart
failure, blood pressure of 126/76 mm Hg, and a respiratory rate of 22
breaths/ minute.
b. The 89-year-old client with end-stage right-sided heart failure,
blood pressure of 78/50 mm Hg, and a “do not resuscitate” order
c. The 62-year-old client who was admitted 1 day ago
with thrombophlebitis and is receiving L.V. heparin
d. The 75-year-old client who was admitted 1 hour ago with new-
onset atrial fibrillation and is receiving L.V. dilitiazem (Cardizem)
46. Honey, a 23-year old client complains of substernal chest pain and states
that her heart feels like “it’s racing out of the chest”. She reports no history of
cardiac disorders. The nurse attaches her to a cardiac monitor and notes
sinus tachycardia with a rate of 136beats/minutes. Breath sounds are clear
and the respiratory rate is 26 breaths/minutes. Which of the following drugs
should the nurse question the client about using?
a. Barbiturates
47. A 51-year-old female client tells the nurse in-charge that she has found a
painless lump in her right breast during her monthly self-examination. Which
assessment finding would strongly suggest that this client's lump is
cancerous?
48. A 35-year-old client with vaginal cancer asks the nurse, "What is the
usual treatment for this type of cancer?" Which treatment should the nurse
name?
a. Surgery
b. Chemotherapy
c. Radiation
d. Immunotherapy
a. Breast cancer
b. Lung cancer
c. Brain cancer
d. Colon and rectal cancer
52. Antonio with lung cancer develops Horner's syndrome when the tumor
invades the ribs and affects the sympathetic nerve ganglia. When assessing
for signs and symptoms of this syndrome, the nurse should note:
a. miosis, partial eyelid ptosis, and anhidrosis on the affected side of the
face.
b. chest pain, dyspnea, cough, weight loss, and fever.
c. arm and shoulder pain and atrophy of arm and hand muscles, both on
the affected side.
d. hoarseness and dysphagia.
53. Vic asks the nurse what PSA is. The nurse should reply that it stands for:
54. What is the most important postoperative instruction that nurse Kate
must give a client who has just returned from the operating room after
receiving a subarachnoid block?
a. Stool Hematest
b. Carcinoembryonic antigen (CEA)
c. Sigmoidoscopy
d. Abdominal computed tomography (CT) scan
57. A female client with cancer is being evaluated for possible metastasis. Which
of the following is one of the most common metastasis sites for cancer cells?
a. Liver
b. Colon
c. Reproductive tract
d. White blood cells (WBCs)
58. Nurse Mandy is preparing a client for magnetic resonance imaging (MRI)
to confirm or rule out a spinal cord lesion. During the MRI scan, which of the
following would pose a threat to the client?
a. Joint pain
b. Joint deformity
c. Joint flexion of less than 50%
d. Joint stiffness
a. Septic arthritis
b. Traumatic arthritis
c. Intermittent arthritis
d. Gouty arthritis
a. 15 ml/hour
b. 30 ml/hour
c. 45 ml/hour
d. 50 ml/hour
63. A 76-year-old male client had a thromboembolic right stroke; his left arm
is swollen. Which of the following conditions may cause swelling after a
stroke?
66. Mrs. Cruz uses a cane for assistance in walking. Which of the
following statements is true about a cane or other assistive devices?
a. aspirin
b. furosemide (Lasix)
c. colchicines
d. calcium gluconate (Kalcinate)
a. Adrenal cortex
b. Pancreas
c. Adrenal medulla
d. Parathyroid
70. For a diabetic male client with a foot ulcer, the doctor orders bed rest, a
wet- to-dry dressing change every shift, and blood glucose monitoring before
meals and bedtime. Why are wet-to-dry dressings used for this client?
71. Nurse Zeny is caring for a client in acute addisonian crisis. Which
laboratory data would the nurse expect to find?
a. Hyperkalemia
73. A female client tells nurse Nikki that she has been working hard for the last
3 months to control her type 2 diabetes mellitus with diet and exercise. To
determine the effectiveness of the client's efforts, the nurse should check:
a. 10:00 am
b. Noon
c. 4:00 pm
d. 10:00 pm
76. On the third day after a partial thyroidectomy, Proserfina exhibits muscle
twitching and hyperirritability of the nervous system. When questioned, the
client reports numbness and tingling of the mouth and fingertips. Suspecting a
life- threatening electrolyte disturbance, the nurse notifies the surgeon
immediately. Which electrolyte disturbance most commonly follows thyroid
surgery?
a. Hypocalcemia
b. Hyponatremia
c. Hyperkalemia
77. Which laboratory test value is elevated in clients who smoke and can't
be used as a general indicator of cancer?
78. Francis with anemia has been admitted to the medical-surgical unit.
Which assessment findings are characteristic of iron-deficiency anemia?
81. Nurse Marie is caring for a 32-year-old client admitted with pernicious
anemia. Which set of findings should the nurse expect when assessing
the client?
83. Mr. Marquez with rheumatoid arthritis is about to begin aspirin therapy to
reduce inflammation. When teaching the client about aspirin, the nurse
discusses adverse reactions to prolonged aspirin therapy. These include:
a. weight gain.
b. fine motor tremors.
c. respiratory acidosis.
d. bilateral hearing loss.
a. Neutrophil
b. Basophil
c. Monocyte
d. Lymphocyte
85. In an individual with Sjögren's syndrome, nursing care should focus on:
a. moisture replacement.
b. electrolyte balance.
c. nutritional supplementation.
d. arrhythmia management.
87. A male client seeks medical evaluation for fatigue, night sweats, and a 20-
lb weight loss in 6 weeks. To confirm that the client has been infected with the
human immunodeficiency virus (HIV), the nurse expects the physician to order:
a. E-rosette immunofluorescence.
b. quantification of T-lymphocytes.
c. enzyme-linked immunosorbent assay (ELISA).
d. Western blot test with ELISA.
90. When taking a dietary history from a newly admitted female client, Nurse
Len should remember that which of the following foods is a common allergen?
a. Bread
b. Carrots
c. Orange
d. Strawberries
91. Nurse John is caring for clients in the outpatient clinic. Which of the
following phone calls should the nurse return first?
a. A client with hepatitis A who states, “My arms and legs are itching.”
b. A client with cast on the right leg who states, “I have a funny feeling
in my right leg.”
c. A client with osteomyelitis of the spine who states, “I am so
nauseous that I can’t eat.”
92. Nurse Sarah is caring for clients on the surgical floor and has just received
report from the previous shift. Which of the following clients should the nurse
see first?
93. Nurse Eve is caring for a client who had a thyroidectomy 12 hours ago for
treatment of Grave’s disease. The nurse would be most concerned if which of
the following was observed?
94. Julius is admitted with complaints of severe pain in the lower right quadrant
of the abdomen. To assist with pain relief, the nurse should take which of the
following actions?
95. Nurse Tina prepares a client for peritoneal dialysis. Which of the
following actions should the nurse take first?
a. The client holds the cane with his right hand, moves the can
forward followed by the right leg, and then moves the left leg.
b. The client holds the cane with his right hand, moves the cane
forward followed by his left leg, and then moves the right leg.
c. The client holds the cane with his left hand, moves the cane
forward followed by the right leg, and then moves the left leg.
d. The client holds the cane with his left hand, moves the cane
forward followed by his left leg, and then moves the right leg.
97. An elderly client is admitted to the nursing home setting. The client is
occasionally confused and her gait is often unsteady. Which of the
following actions, if taken by the nurse, is most appropriate?
98. Nurse Evangeline teaches an elderly client how to use a standard aluminum
walker. Which of the following behaviors, if demonstrated by the client,
indicates that the nurse’s teaching was effective?
a. Pain
b. Weight
c. Hematuria
d. Hypertension
4. Ricardo, was diagnosed with type I diabetes. The nurse is aware that
acute hypoglycemia also can develop in the client who is diagnosed
with:
a. Liver disease
b. Hypertension
c. Type 2 diabetes
d. Hyperthyroidism
a. Ascites
b. Nystagmus
c. Leukopenia
d. Polycythemia
a. Administer Kayexalate
b. Restrict foods high in protein
c. Increase oral intake of cheese and milk.
d. Administer large amounts of normal saline via I.V.
9. Mario has burn injury. After Forty48 hours, the physician orders for Mario
2 liters of IV fluid to be administered q12 h. The drop factor of the tubing
is 10 gtt/ml. The nurse should set the flow to provide:
a. 18 gtt/min
b. 28 gtt/min
c. 32 gtt/min
d. 36 gtt/min
10. Terence suffered form burn injury. Using the rule of nines, which has
the largest percent of burns?
a. Reactive pupils
b. A depressed fontanel
c. Bleeding from ears
d. An elevated temperature
12. Nurse Sherry is teaching male client regarding his permanent artificial
pacemaker. Which information given by the nurse shows her
knowledge deficit about the artificial cardiac pacemaker?
a. take the pulse rate once a day, in the morning upon awakening
b. May be allowed to use electrical appliances
c. Have regular follow up care
d. May engage in contact sports
13. The nurse is ware that the most relevant knowledge about
oxygen administration to a male client with COPD is
16. Nurse Tristan is caring for a male client in acute renal failure. The
nurse should expect hypertonic glucose, insulin infusions, and sodium
bicarbonate to be used to treat:
a. hypernatremia.
b. hypokalemia.
c. hyperkalemia.
d. hypercalcemia.
a. The left kidney usually is slightly higher than the right one.
b. The kidneys are situated just above the adrenal glands.
c. The average kidney is approximately 5 cm (2") long and 2 to 3
cm (¾" to 1-1/8") wide.
d. The kidneys lie between the 10th and 12th thoracic vertebrae.
19. Jestoni with chronic renal failure (CRF) is admitted to the urology unit.
The nurse is aware that the diagnostic test are consistent with CRF if the
result is:
21. During a routine checkup, Nurse Mariane assesses a male client with
acquired immunodeficiency syndrome (AIDS) for signs and symptoms
of cancer. What is the most common AIDS-related cancer?
a. To prevent confusion
b. To prevent seizures
c. To prevent cerebrospinal fluid (CSF) leakage
d. To prevent cardiac arrhythmias
23.A A male client had a nephrectomy 2 days ago and is now complaining
of abdominal pressure and nausea. The first nursing action should be
to:
24. Wilfredo with a recent history of rectal bleeding is being prepared for a
colonoscopy. How should the nurse Patricia position the client for this
test initially?
27. Nurse Ron is assessing a client admitted with second- and third-
degree burns on the face, arms, and chest. Which finding indicates a
potential problem?
28. Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too
weak to move on his own. To help the client avoid pressure ulcers,
Nurse Celia should:
31.A A male client has jugular distention. On what position should the
nurse place the head of the bed to obtain the most accurate reading of
jugular vein distention?
a. High Fowler’s
b. Raised 10 degrees
c. Raised 30 degrees
d. Supine position
32. The nurse is aware that one of the following classes of medications
maximizes cardiac performance in clients with heart failure by
increasing ventricular contractility?
a. Beta-adrenergic blockers
b. Calcium channel blocker
c. Diuretics
d. Inotropic agents
33.A A male client has a reduced serum high-density lipoprotein (HDL) level
and an elevated low-density lipoprotein (LDL) level. Which of the
following dietary modifications is not appropriate for this client?
a. 46 mm Hg
b. 80 mm Hg
c. 95 mm Hg
d. 90 mm Hg
37. A female client arrives at the emergency department with chest and
stomach pain and a report of black tarry stool for several months. Which of the
following order should the nurse Oliver anticipate?
38. Macario had coronary artery bypass graft (CABG) surgery 3 days ago.
Which of the following conditions is suspected by the nurse when a decrease in
platelet count from 230,000 ul to 5,000 ul is noted?
a. Pancytopenia
b. Idiopathic thrombocytopemic purpura (ITP)
c. Disseminated intravascular coagulation (DIC)
d. Heparin-associated thrombosis and thrombocytopenia (HATT)
a. Allogeneic
b. Autologous
c. Syngeneic
d. Xenogeneic
41. Marco falls off his bicycle and injuries his ankle. Which of the
following actions shows the initial response to the injury in the extrinsic
pathway?
a. Release of Calcium
b. Release of tissue thromboplastin
c. Conversion of factors XII to factor XIIa
d. Conversion of factor VIII to factor VIIIa
a. Dressler’s syndrome
b. Polycythemia
c. Essential thrombocytopenia
43. The nurse is aware that the following symptoms is most commonly an
early indication of stage 1 Hodgkin’s disease?
a. Pericarditis
b. Night sweat
c. Splenomegaly
d. Persistent hypothermia
44. Francis with leukemia has neutropenia. Which of the following functions
must frequently assessed?
a. Blood pressure
b. Bowel sounds
c. Heart sounds
d. Breath sounds
a. Brain
b. Muscle spasm
c. Renal dysfunction
d. Myocardial irritability
46. Nurse Patricia is aware that the average length of time from
human immunodeficiency virus (HIV) infection to the development of
acquired immunodeficiency syndrome (AIDS)?
47. An 18-year-old male client admitted with heat stroke begins to show signs
of disseminated intravascular coagulation (DIC). Which of the following
laboratory findings is most consistent with DIC?
a. Influenza
b. Sickle cell anemia
c. Leukemia
d. Hodgkin’s disease
a. AB Rh-positive
b. A Rh-positive
c. A Rh-negative
d. O Rh-positive
51. Stacy’s mother states to the nurse that it is hard to see Stacy with no
hair. The best response for the nurse is:
52. Stacy has beginning stomatitis. To promote oral hygiene and comfort,
the nurse in-charge should:
54. The term “blue bloater” refers to a male client which of the
following conditions?
55. The term “pink puffer” refers to the female client with which of the
following conditions?
a. 15 mm Hg
b. 30 mm Hg
c. 40 mm Hg
d. 80 mm Hg
57. Timothy’s arterial blood gas (ABG) results are as follows; pH 7.16; Paco2 80
mm Hg; Pao2 46 mm Hg; HCO3- 24mEq/L; Sao2 81%. This ABG result
represents which of the following conditions?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
58. Norma has started a new drug for hypertension. Thirty minutes after she
takes the drug, she develops chest tightness and becomes short of breath and
tachypneic. She has a decreased level of consciousness. These signs
indicate which of the following conditions?
a. Asthma attack
b. Pulmonary embolism
c. Respiratory failure
d. Rheumatoid arthritis
Situation: Mr. Gonzales was admitted to the hospital with ascites and
jaundice. To rule out cirrhosis of the liver:
a. Cardiac catheterization
b. Echocardiogram
c. Nitroglycerin
d. Percutaneous transluminal coronary angioplasty (PTCA)
66. The nurse is aware that the following terms used to describe reduced
cardiac output and perfusion impairment due to ineffective pumping of the heart
is:
a. Anaphylactic shock
b. Cardiogenic shock
c. Distributive shock
d. Myocardial infarction (MI)
67. A client with hypertension ask the nurse which factors can cause
blood pressure to drop to normal levels?
68. Nurse Rose is aware that the statement that best explains why furosemide
(Lasix) is administered to treat hypertension is:
69. Nurse Nikki knows that laboratory results supports the diagnosis of
systemic lupus erythematosus (SLE) is:
70. Arnold, a 19-year-old client with a mild concussion is discharged from the
emergency department. Before discharge, he complains of a headache.
When offered acetaminophen, his mother tells the nurse the headache is
severe and she would like her son to have something stronger. Which of the
following responses by the nurse is appropriate?
71. When evaluating an arterial blood gas from a male client with a
subdural hematoma, the nurse notes the Paco2 is 30 mm Hg. Which of the
following responses best describes the result?
72. When prioritizing care, which of the following clients should the nurse
Olivia assess first?
73. JP has been diagnosed with gout and wants to know why colchicine is
used in the treatment of gout. Which of the following actions of colchicines
explains why it’s effective for gout?
a. Replaces estrogen
b. Decreases infection
c. Decreases inflammation
d. Decreases bone demineralization
75. Ruby is receiving thyroid replacement therapy develops the flu and forgets
to take her thyroid replacement medicine. The nurse understands that skipping
this medication will put the client at risk for developing which of the following life-
threatening complications?
a. Exophthalmos
b. Thyroid storm
c. Myxedema coma
d. Tibial myxedema
77. Cyrill with severe head trauma sustained in a car accident is admitted to the
intensive care unit. Thirty-six hours later, the client's urine output suddenly
rises above 200 ml/hour, leading the nurse to suspect diabetes insipidus.
Which laboratory findings support the nurse's suspicion of diabetes insipidus?
a. Diabetes mellitus
b. Diabetes insipidus
c. Hypoparathyroidism
d. Hyperparathyroidism
83. Capillary glucose monitoring is being performed every 4 hours for a client
diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of
regular insulin according to glucose results. At 2 p.m., the client has a
capillary glucose level of 250 mg/dl for which he receives 8 U of regular
insulin. Nurse Mariner should expect the dose's:
85. Rico with diabetes mellitus must learn how to self-administer insulin. The
physician has prescribed 10 U of U-100 regular insulin and 35 U of U-100
isophane insulin suspension (NPH) to be taken before breakfast. When teaching
the client how to select and rotate insulin injection sites, the nurse should
provide which instruction?
a. "Inject insulin into healthy tissue with large blood vessels and nerves."
b. "Rotate injection sites within the same anatomic region, not
among different regions."
86. Nurse Sarah expects to note an elevated serum glucose level in a client
with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other
laboratory finding should the nurse anticipate?
a. Asthma attack
b. Atelectasis
c. Bronchitis
d. Fat embolism
92. A client with shortness of breath has decreased to absent breath sounds on
the right side, from the apex to the base. Which of the following conditions
would best explain this?
a. Acute asthma
b. Chronic bronchitis
c. Pneumonia
d. Spontaneous pneumothorax
a. Bronchitis
b. Pneumonia
c. Pneumothorax
d. Tuberculosis (TB)
96. Aldo with a massive pulmonary embolism will have an arterial blood gas
analysis performed to determine the extent of hypoxia. The acid-base
disorder that may be present is?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
97. After a motor vehicle accident, Armand an 22-year-old client is admitted with
a pneumothorax. The surgeon inserts a chest tube and attaches it to a chest
drainage system. Bubbling soon appears in the water seal chamber. Which of
the following is the most likely cause of the bubbling?
a. Air leak
b. Adequate suction
c. Inadequate suction
d. Kinked chest tube
98. Nurse Michelle calculates the IV flow rate for a postoperative client. The
client receives 3,000 ml of Ringer’s lactate solution IV to run over 24 hours.
The IV infusion set has a drop factor of 10 drops per milliliter. The nurse should
regulate the client’s IV to deliver how many drops per minute?
a. 18
b. 21
c. 35
d. 40
99. Mickey, a 6-year-old child with a congenital heart disorder is admitted with
congestive heart failure. Digoxin (lanoxin) 0.12 mg is ordered for the child.
The bottle of Lanoxin contains .05 mg of Lanoxin in 1 ml of solution. What
amount should the nurse administer to the child?
a. 1.2 ml
b. 2.4 ml
c. 3.5 ml
d. 4.2 ml
1. Mr. Marquez reports of losing his job, not being able to sleep at night, and
feeling upset with his wife. Nurse John responds to the client, “You may
want to talk about your employment situation in group today.” The Nurse
is using which therapeutic technique?
a. Observations
b. Restating
c. Exploring
d. Focusing
3. Tina who is manic, but not yet on medication, comes to the drug
treatment center. The nurse would not let this client join the group session
because:
a. Inform the mother that she and the father can work through
this problem themselves.
b. Refer the mother to the hospital social worker.
c. Agree to talk with the mother and the father together.
d. Suggest that the father and son work things out.
6. Aira has taken amitriptyline HCL (Elavil) for 3 days, but now complains
that it “doesn’t help” and refuses to take it. What should the nurse say
or do?
a. Id
b. Ego
c. Superego
d. Oedipal complex
a. Short-acting anesthesia
b. Decreased oral and respiratory secretions.
c. Skeletal muscle paralysis.
d. Analgesia.
12. After seeking help at an outpatient mental health clinic, Ruby who was
raped while walking her dog is diagnosed with posttraumatic stress
disorder (PTSD). Three months later, Ruby returns to the clinic,
complaining of fear, loss of control, and helpless feelings. Which
nursing intervention is most appropriate for Ruby?
13. Meryl, age 19, is highly dependent on her parents and fears leaving
home to go away to college. Shortly before the semester starts, she
complains that her legs are paralyzed and is rushed to the emergency
department. When physical examination rules out a physical cause for
her paralysis, the physician admits her to the psychiatric unit where she is
diagnosed with conversion disorder. Meryl asks the nurse, "Why has this
happened to me?" What is the nurse's best response?
15. Alfred was newly diagnosed with anxiety disorder. The physician
prescribed buspirone (BuSpar). The nurse is aware that the teaching
instructions for newly prescribed buspirone should include which of
the following?
a. Antidepressants
b. Anticholinergics
c. Antipsychotics
d. Mood stabilizers
18.A A client seeks care because she feels depressed and has gained
weight. To treat her atypical depression, the physician prescribes
tranylcypromine sulfate (Parnate), 10 mg by mouth twice per day. When
this drug is used to treat atypical depression, what is its onset of action?
a. 1 to 2 days
b. 3 to 5 days
c. 6 to 8 days
19. A 65 years old client is in the first stage of Alzheimer's disease. Nurse
Patricia should plan to focus this client's care on:
20. The nurse is assessing a client who has just been admitted to the
emergency department. Which signs would suggest an overdose of
an antianxiety agent?
21. The nurse is caring for a client diagnosed with antisocial personality
disorder. The client has a history of fighting, cruelty to animals, and
stealing. Which of the following traits would the nurse be most likely
to uncover during assessment?
22. Nurse Amy is providing care for a male client undergoing opiate
withdrawal. Opiate withdrawal causes severe physical discomfort and
can be life-threatening. To minimize these effects, opiate users are
commonly detoxified with:
a. Barbiturates
b. Amphetamines
c. Methadone
d. Benzodiazepines
23. Nurse Cristina is caring for a client who experiences false sensory
perceptions with no basis in reality. These perceptions are known
as:
a. Delusions
b. Hallucinations
a. Restricts visits with the family and friends until the client begins
to eat.
b. Provide privacy during meals.
c. Set up a strict eating plan for the client.
d. Encourage the client to exercise, which will reduce her anxiety.
26. Nurse Jen is caring for a male client with manic depression. The plan
of care for a client in a manic state would include:
27. Ramon is admitted for detoxification after a cocaine overdose. The client
tells the nurse that he frequently uses cocaine but that he can control
his use if he chooses. Which coping mechanism is he using?
a. Withdrawal
b. Logical thinking
c. Repression
d. Denial
a. Aggressive behavior
b. Paranoid thoughts
29. Nurse Mickey is caring for a client diagnosed with bulimia. The
most appropriate initial goal for a client diagnosed with bulimia is to:
31. Nicolas is experiencing hallucinations tells the nurse, “The voices are
telling me I’m no good.” The client asks if the nurse hears the voices.
The most appropriate response by the nurse would be:
a. “It is the voice of your conscience, which only you can control.”
b. “No, I do not hear your voices, but I believe you can hear them”.
c. “The voices are coming from within you and only you can
hear them.”
d. “Oh, the voices are a symptom of your illness; don’t pay
any attention to them.”
32. The nurse is aware that the side effect of electroconvulsive therapy that
a client may experience:
a. Loss of appetite
b. Postural hypotension
c. Confusion for a time after treatment
d. Complete loss of memory for a time
a. Anger stage
b. Denial stage
c. Bargaining stage
a. Driving at night
b. Staying in the sun
c. Ingesting wines and cheeses
d. Taking medications containing aspirin
a. Mild-level anxiety
b. Panic-level anxiety
c. Severe-level anxiety
d. Moderate-level anxiety
a. Rigidity
b. Stubbornness
c. Diverse interest
d. Over meticulousness
38. Nurse Krina recognizes that the suicidal risk for depressed client is
greatest:
41. The psychiatrist orders lithium carbonate 600 mg p.o t.i.d for a female
client. Nurse Katrina would be aware that the teaching about the side
effects of this drug were understood when the client state, “I will call
my doctor immediately if I notice any:
42. Nurse Mylene recognizes that the most important factor necessary for
the establishment of trust in a critical care area is:
a. Privacy
b. Respect
c. Empathy
d. Presence
45. Nurse John is a aware that most crisis situations should resolve in about:
a. 1 to 2 weeks
b. 4 to 6 weeks
c. 4 to 6 months
d. 6 to 12 months
46. Nurse Judy knows that statistics show that in adolescent suicide
behavior:
a. phenelzine (Nardil)
b. chlordiazepoxide (Librium)
c. lithium carbonate (Lithane)
d. imipramine (Tofranil)
49. Which information is most important for the nurse Trinity to include in a
teaching plan for a male schizophrenic client taking clozapine
(Clozaril)?
a. Tardive dyskinesia.
b. Dystonia.
c. Neuroleptic malignant syndrome.
d. Akathisia.
52. Mr. Cruz visits the physician's office to seek treatment for depression,
feelings of hopelessness, poor appetite, insomnia, fatigue, low self-
esteem, poor concentration, and difficulty making decisions. The
client states that these symptoms began at least 2 years ago. Based
on this report, the nurse Tyfany suspects:
a. Cyclothymic disorder.
b. Atypical affective disorder.
c. Major depression.
d. Dysthymic disorder.
a. Ginkgo biloba
b. Echinacea
c. St. John's wort
d. Ephedra
55. Cely with manic episodes is taking lithium. Which electrolyte level
should the nurse check before administering this medication?
a. Calcium
b. Sodium
c. Chloride
d. Potassium
56. Nurse Josefina is caring for a client who has been diagnosed
with delirium. Which statement about delirium is true?
57. Edward, a 66 year old client with slight memory impairment and poor
concentration is diagnosed with primary degenerative dementia of the
Alzheimer's type. Early signs of this dementia include subtle personality
changes and withdrawal from social interactions. To assess for
progression to the middle stage of Alzheimer's disease, the nurse
should observe the client for:
a. Alcohol withdrawal
b. Cannibis withdrawal
c. Cocaine withdrawal
d. Opioid withdrawal
61. Mr. Garcia, an attorney who throws books and furniture around the
office after losing a case is referred to the psychiatric nurse in the law
firm's employee assistance program. Nurse Beatriz knows that the
client's behavior most likely represents the use of which defense
mechanism?
a. Regression
b. Projection
c. Reaction-formation
d. Intellectualization
62. Nurse Anne is caring for a client who has been treated long term with
antipsychotic medication. During the assessment, Nurse Anne checks
the client for tardive dyskinesia. If tardive dyskinesia is present, Nurse
Anne would most likely observe:
a. Weakness
b. Diarrhea
c. Blurred vision
d. Fecal incontinence
64. Nurse Jannah is monitoring a male client who has been placed
inrestraints because of violent behavior. Nurse determines that it will be
safe to remove the restraints when:
65. Nurse Irish is aware that Ritalin is the drug of choice for a child with
ADHD. The side effects of the following may be noted by the
nurse:
66. Kitty, a 9 year old child has very limited vocabulary and interaction skills.
She has an I.Q. of 45. She is diagnosed to have Mental retardation of
this classification:
a. Profound
b. Mild
c. Moderate
d. Severe
68. Jeremy is brought to the emergency room by friends who state that he
took something an hour ago. He is actively hallucinating, agitated,
with
Nursing Crib – Student Nurses’ Community 107
irritated nasal septum.
a. Heroin
b. Cocaine
c. LSD
d. Marijuana
69. Nurse Pauline is aware that Dementia unlike delirium is characterized by:
a. Slurred speech
b. Insidious onset
c. Clouding of consciousness
d. Sensory perceptual change
70.A A 35 year old female has intense fear of riding an elevator. She
claims “ As if I will die inside.” The client is suffering from:
a. Agoraphobia
b. Social phobia
c. Claustrophobia
d. Xenophobia
73. Nurse Sarah ensures a therapeutic environment for all the client. Which
of the following best describes a therapeutic milieu?
74. Anthony is very hostile toward one of the staff for no apparent reason.
He is manifesting:
a. Splitting
b. Transference
c. Countertransference
d. Resistance
75. Marielle, 17 years old was sexually attacked while on her way home
from school. She is brought to the hospital by her mother. Rape is an
example of which type of crisis:
a. Situational
b. Adventitious
c. Developmental
d. Internal
a. Obesity
b. Borderline personality disorder
c. Major depression
d. Hypertension
77. Katrina, a newly admitted is extremely hostile toward a staff member she
has just met, without apparent reason. According to Freudian theory, the
nurse should suspect that the client is experiencing which of the
following phenomena?
a. Intellectualization
b. Transference
c. Triangulation
d. Splitting
a. Conversion disorder
b. Hypochondriasis
c. Severe anxiety
79. Charina, a college student who frequently visited the health center during
the past year with multiple vague complaints of GI symptoms before course
examinations. Although physical causes have been eliminated, the student
continues to express her belief that she has a serious illness. These symptoms
are typically of which of the following disorders?
a. Conversion disorder
b. Depersonalization
c. Hypochondriasis
d. Somatization disorder
80. Nurse Daisy is aware that the following pharmacologic agents are
sedative- hypnotic medication is used to induce sleep for a client experiencing
a sleep disorder is:
a. Triazolam (Halcion)
b. Paroxetine (Paxil)\
c. Fluoxetine (Prozac)
d. Risperidone (Risperdal)
81. Aldo, with a somatoform pain disorder may obtain secondary gain. Which
of the following statement refers to a secondary gain?
82. Dervid is diagnosed with panic disorder with agoraphobia is talking with
the nurse in-charge about the progress made in treatment. Which of the
following statements indicates a positive client response?
84. Mark, with a diagnosis of generalized anxiety disorder wants to stop taking
his lorazepam (Ativan). Which of the following important facts should nurse
Betty discuss with the client about discontinuing the medication?
a. Anxiety disorder
b. Behavioral difficulties
c. Cognitive impairment
d. Labile moods
87. The nurse is aware that the following ways in vascular dementia
different from Alzheimer’s disease is:
88. Loretta, a newly admitted client was diagnosed with delirium and has
history of hypertension and anxiety. She had been taking digoxin, furosemide
(Lasix), and diazepam (Valium) for anxiety. This client’s impairment may be
related to which of the following conditions?
a. Infection
b. Metabolic acidosis
89. Nurse Ron enters a client’s room, the client says, “They’re crawling on
my sheets! Get them off my bed!” Which of the following assessment is the
most accurate?
a. The client tries to hit the nurse when vital signs must be taken
b. The client says, “I keep hearing a voice telling me to run away”
c. The client becomes anxious whenever the nurse leaves
the bedside
d. The client looks at the shadow on a wall and tells the nurse
she sees frightening faces on the wall.
91. During conversation of Nurse John with a client, he observes that the
client shift from one topic to the next on a regular basis. Which of the following
terms describes this disorder?
a. Flight of ideas
b. Concrete thinking
c. Ideas of reference
d. Loose association
92. Francis tells the nurse that her coworkers are sabotaging the
computer. When the nurse asks questions, the client becomes
argumentative. This behavior shows personality traits associated with
which of the following personality disorder?
a. Antisocial
b. Histrionic
c. Paranoid
d. Schizotypal
94. Nurse Alexandra notices other clients on the unit avoiding a client
diagnosed with antisocial personality disorder. When discussing appropriate
behavior in group therapy, which of the following comments is expected about
this client by his peers?
a. Lack of honesty
b. Belief in superstition
c. Show of temper tantrums
d. Constant need for attention
a. “I’m not going to look just at the negative things about myself”
b. “I’m most concerned about my level of competence and progress”
c. “I’m not as envious of the things other people have as I used to be”
d. “I find I can’t stop myself from taking over things other should
be doing”
97. Ivy, who is on the psychiatric unit is copying and imitating the movements
of her primary nurse. During recovery, she says, “I thought the nurse was my
mirror. I felt connected only when I saw my nurse.” This behavior is known by
which of the following terms?
a. Modeling
b. Echopraxia
c. Ego-syntonicity
d. Ritualism
a. Delusion
b. Disorganized speech
c. Hallucination
d. Idea of reference
a. Projection
b. Rationalization
c. Regression
d. Repression
ANSWERS
&
RATIONALE
18. Answer: (D) Sudden onset of continuous epigastric and back pain.
Rationale: The autodigestion of tissue by the pancreatic enzymes results
in pain from inflammation, edema, and possible hemorrhage. Continuous,
unrelieved epigastric or back pain reflects the inflammatory process in
the pancreas.
21. Answer: (D) Immobilize the leg before moving the client.
Rationale: If the nurse suspects a fracture, splinting the area before
moving the client is imperative. The nurse should call for emergency help
if the client is not hospitalized and call for a physician for the hospitalized
client.
24. Answer: (B) Place the client on the left side in the Trendelenburg
position. Rationale: Lying on the left side may prevent air from flowing
into the pulmonary veins. The Trendelenburg position increases
intrathoracic pressure, which decreases the amount of blood pulled into
the vena cava during aspiration.
30. Answer: (A) Take the proper equipment, place the client in a
comfortable position, and record the appropriate information in the
client’s chart. Rationale: It is a general or comprehensive statement
about the correct procedure, and it includes the basic ideas which are
found in the other options
33. Answer: (A) Trochanter roll extending from the crest of the ileum to
the mid-thigh.
Rationale: A trochanter roll, properly placed, provides resistance to the
external rotation of the hip.
38. Answer: (D) It’s a measure of effect, not a standard measure of weight
or quantity.
Rationale: An insulin unit is a measure of effect, not a standard measure
of weight or quantity. Different drugs measured in units may have no
relationship to one another in quality or quantity.
50. Answer: (B) To provide support for the client and family in coping
with terminal illness.
Rationale: Hospices provide supportive care for terminally ill clients and
their families. Hospice care doesn’t focus on counseling regarding health
care costs. Most client referred to hospices have been treated for their
disease without success and will receive only palliative care in the
hospice.
51. Answer: (C) Using normal saline solution to clean the ulcer and
applying a protective dressing as necessary.
Rationale: Washing the area with normal saline solution and applying a
protective dressing are within the nurse’s realm of interventions and will
protect the area. Using a povidone-iodine wash and an antibiotic cream
require a physician’s order. Massaging with an astringent can further
damage the skin.
58. Answer: (D ) Obtaining the specimen from the urinary drainage bag.
Rationale: A urine specimen is not taken from the urinary drainage
bag. Urine undergoes chemical changes while sitting in the bag and
does not necessarily reflect the current client status. In addition, it may
become contaminated with bacteria from opening the system.
59. Answer: (B) Cover the client, place the call light within reach, and
answer the phone call.
Rationale: Because telephone call is an emergency, the nurse may need
to answer it. The other appropriate action is to ask another nurse to
accept the call. However, is not one of the options. To maintain privacy
and safety, the nurse covers the client and places the call light within the
client’s reach. Additionally, the client’s door should be closed or the room
curtains pulled around the bathing area.
60. Answer: (C) Use a sterile plastic container for obtaining the specimen.
Rationale: Sputum specimens for culture and sensitivity testing need to
be obtained using sterile techniques because the test is done to
determine the presence of organisms. If the procedure for obtaining the
specimen is not sterile, then the specimen is not sterile, then the
specimen would be contaminated and the results of the test would be
invalid.
Rationale: When the client uses a walker, the nurse stands adjacent to
the affected side. The client is instructed to put all four points of the
walker 2 feet forward flat on the floor before putting weight on hand
pieces. This will ensure client safety and prevent stress cracks in the
walker. The client is then instructed to move the walker forward and walk
into it.
62. Answer: (C) Draws one line to cross out the incorrect information
and then initials the change.
Rationale: To correct an error documented in a medical record, the nurse
draws one line through the incorrect information and then initials the error.
An error is never erased and correction fluid is never used in the medical
record.
63. Answer: (C) Secures the client safety belts after transferring to
the stretcher.
Rationale: During the transfer of the client after the surgical procedure is
complete, the nurse should avoid exposure of the client because of the
risk for potential heat loss. Hurried movements and rapid changes in the
position should be avoided because these predispose the client to
hypotension. At the time of the transfer from the surgery table to the
stretcher, the client is still affected by the effects of the anesthesia;
therefore, the client should not move self. Safety belts can prevent the
client from falling off the stretcher.
66. Answer: (D) Left side-lying with the head of the bed elevated 45 degrees.
Rationale: To facilitate removal of fluid from the chest wall, the client is
positioned sitting at the edge of the bed leaning over the bedside table
with the feet supported on a stool. If the client is unable to sit up, the
client is positioned lying in bed on the unaffected side with the head of the
bed elevated 30 to 45 degrees.
75. Answer: (B) The Board can investigate violations of the nursing law
and code of ethics
Rationale: Quasi-judicial power means that the Board of Nursing has the
authority to investigate violations of the nursing law and can issue
summons, subpoena or subpoena duces tecum as needed.
89. Answer: (A) Arrange for typing and cross matching of the client’s blood.
Rationale: The nurse first arranges for typing and cross matching of the
client's blood to ensure compatibility with donor blood. The other
options, although appropriate when preparing to administer a blood
transfusion, come later.
94. Answer: (B) Decrease the rate of feedings and the concentration of
the formula.
Rationale: Complaints of abdominal discomfort and nausea are common
in clients receiving tube feedings. Decreasing the rate of the feeding and
the concentration of the formula should decrease the client's discomfort.
Feedings are normally given at room temperature to minimize abdominal
cramping. To prevent aspiration during feeding, the head of the client's
bed should be elevated at least 30 degrees. Also, to prevent bacterial
growth, feeding containers should be routinely changed every 8 to 12
hours.
95. Answer: (D) Roll the vial gently between the palms.
Rationale: Rolling the vial gently between the palms produces heat,
which helps dissolve the medication. Doing nothing or inverting the vial
wouldn't help dissolve the medication. Shaking the vial vigorously could
cause the medication to break down, altering its action.
96. Answer: (B) Assist the client to the semi-Fowler position if possible.
99. Answer: (A) The nurse can implement medication orders quickly.
Rationale: A floor stock system enables the nurse to implement
medication orders quickly. It doesn't allow for pharmacist input, nor does
it minimize transcription errors or reinforce accurate calculations.
10. Answer: (D) First low transverse caesarean was for breech
position. Fetus in this pregnancy is in a vertex presentation.
Rationale: This type of client has no obstetrical indication for a caesarean
section as she did with her first caesarean delivery.
11. Answer: (A) Talk to the mother first and then to the toddler.
Rationale: When dealing with a crying toddler, the best approach is to
talk to the mother and ignore the toddler first. This approach helps the
toddler get used to the nurse before she attempts any procedures. It also
gives the toddler an opportunity to see that the mother trusts the nurse.
12. Answer: (D) Place the infant’s arms in soft elbow restraints.
Rationale: Soft restraints from the upper arm to the wrist prevent the
infant from touching her lip but allow him to hold a favorite item such as a
blanket. Because they could damage the operative site, such as objects
as pacifiers, suction catheters, and small spoons shouldn’t be placed in a
baby’s mouth after cleft repair. A baby in a prone position may rub her
face on the sheets and traumatize the operative site. The suture line
should be cleaned gently to prevent infection, which could interfere with
healing and damage the cosmetic appearance of the repair.
21. Answer: (B) Health education and community organizing are necessary
in providing community health services.
Rationale: The community health nurse develops the health capability of
people through health education and community organizing activities.
34. Answer: (D) A 2 year old infant with stridorous breath sounds, sitting up
in his mother’s arms and drooling.
Rationale: The infant with the airway emergency should be treated first,
because of the risk of epiglottitis.
38. Answer: (D) “I really need to use the diaphragm and jelly most during
the middle of my menstrual cycle”.
Rationale: The woman must understand that, although the “fertile” period
is approximately mid-cycle, hormonal variations do occur and can result in
early or late ovulation. To be effective, the diaphragm should be inserted
before every intercourse.
40. Answer: (B) Walk one step ahead, with the child’s hand on the
nurse’s elbow.
Rationale: This procedure is generally recommended to follow in guiding
a person who is blind.
42. Answer: (C) More oxygen, and the newborn’s metabolic rate
increases. Rationale: When cold, the infant requires more oxygen and
there is an increase in metabolic rate. Non-shievering thermogenesis is
a complex process that increases the metabolic rate and rate of oxygen
consumption, therefore, the newborn increase heat production.
46. Answer: (A) The older one gets, the more susceptible he becomes to
the complications of chicken pox.
Rationale: Chicken pox is usually more severe in adults than in children.
Complications, such as pneumonia, are higher in incidence in adults.
63. Answer: (D) Let the child rest for 10 minutes then continue giving
Oresol more slowly.
Rationale: If the child vomits persistently, that is, he vomits everything
that he takes in, he has to be referred urgently to a hospital. Otherwise,
vomiting is managed by letting the child rest for 10 minutes and then
continuing with Oresol administration. Teach the mother to give Oresol
more slowly.
76. Answer: (C) Keep the cord dry and open to air
Rationale: Keeping the cord dry and open to air helps reduce infection
and hastens drying. Infants aren’t given tub bath but are sponged off until
the cord falls off. Petroleum jelly prevents the cord from drying and
encourages infection. Peroxide could be painful and isn’t recommended.
80. Answer: (B) Instructing the client to use two or more peripads to cushion
the area
Rationale: Using two or more peripads would do little to reduce the pain
or promote perineal healing. Cold applications, sitz baths, and Kegel
exercises are important measures when the client has a fourth-degree
laceration.
82. Answer: (D) Aspirate the neonate’s nose and mouth with a bulb syringe.
Rationale: The nurse's first action should be to clear the neonate's airway
with a bulb syringe. After the airway is clear and the neonate's color
improves, the nurse should comfort and calm the neonate. If the problem
recurs or the neonate's color doesn't improve readily, the nurse should
notify the physician. Administering oxygen when the airway isn't clear
would be ineffective.
83. Answer: (C) Conducting a bedside ultrasound for an amniotic fluid index.
96. Answer: (B) Rh-positive fetal blood crosses into maternal blood,
stimulating maternal antibodies.
Rationale: Rh isoimmunization occurs when Rh-positive fetal blood cells
cross into the maternal circulation and stimulate maternal antibody
production. In subsequent pregnancies with Rh-positive fetuses, maternal
antibodies may cross back into the fetal circulation and destroy the fetal
blood cells.
6. Answer: (C) Make sure that the client takes food and medications
at prescribed intervals.
Rationale: Food and drug therapy will prevent the accumulation of
hydrochloric acid, or will neutralize and buffer the acid that does
accumulate.
10. Answer: (C) The client is oriented when aroused from sleep, and
goes back to sleep immediately.
Rationale: This finding suggest that the level of consciousness is
decreasing.
21. Answer: (C) Balance the client’s periods of activity and rest.
Rationale: A client with hyperthyroidism needs to be encouraged to
balance periods of activity and rest. Many clients with hyperthyroidism are
hyperactive and complain of feeling very warm.
30. Answer: (D) Place the client on his side, remove dangerous objects,
and protect his head.
Rationale: During the active seizure phase, initiate precautions by placing
the client on his side, removing dangerous objects, and protecting his
head from injury. A bite block should never be inserted during the active
seizure phase. Insertion can break the teeth and lead to aspiration.
32. Answer: (D) Stay with him but not intervene at this time.
Rationale: If the client is coughing, he should be able to dislodge the
object or cause a complete obstruction. If complete obstruction occurs, the
nurse should perform the abdominal thrust maneuver with the client
standing. If the client is unconscious, she should lay him down. A nurse
should never leave a choking client alone.
34. Answer: (C) Place the client in a side lying position, with the head of
the bed lowered.
Rationale: The client should be positioned in a side-lying position with the
head of the bed lowered to prevent aspiration. A small amount of
toothpaste should be used and the mouth swabbed or suctioned to
remove pooled secretions. Lemon glycerin can be drying if used for
extended periods. Brushing the teeth with the client lying supine may lead
to aspiration. Hydrogen peroxide is caustic to tissues and should not be
used.
40. Answer: (A) The patient is under local anesthesia during the procedure
Rationale: Before the procedure, the patient is administered with drugs
that would help to prevent infection and rejection of the transplanted
cells such as antibiotics, cytotoxic, and corticosteroids. During the
transplant, the patient is placed under general anesthesia.
44. Answer: (A) Explain the risks of not having the surgery
Rationale: The best initial response is to explain the risks of not having
the surgery. If the client understands the risks but still refuses the nurse
should notify the physician and the nurse supervisor and then record the
client’s refusal in the nurses’ notes.
45. Answer: (D) The 75-year-old client who was admitted 1 hour ago with
new-onset atrial fibrillation and is receiving L.V. dilitiazem (Cardizem)
Rationale: The client with atrial fibrillation has the greatest potential to
become unstable and is on L.V. medication that requires close monitoring.
After assessing this client, the nurse should assess the client with
thrombophlebitis who is receiving a heparin infusion, and then the 58-
year-old client admitted 2 days ago with heart failure (his signs and
symptoms are resolving and don’t require immediate attention). The
lowest priority is the 89-year-old with end-stage right-sided heart failure,
who requires time-consuming supportive measures.
49. Answer: (B) Carcinoma in situ, no abnormal regional lymph nodes, and
no evidence of distant metastasis
Rationale: TIS, N0, M0 denotes carcinoma in situ, no abnormal regional
lymph nodes, and no evidence of distant metastasis. No evidence of
primary tumor, no abnormal regional lymph nodes, and no evidence of
distant metastasis is classified as T0, N0, M0. If the tumor and regional
lymph nodes can't be assessed and no evidence of metastasis exists, the
lesion is classified as TX, NX, M0. A progressive increase in tumor size,
no demonstrable metastasis of the regional lymph nodes, and ascending
degrees of distant metastasis is classified as T1, T2, T3, or T4; N0; and
M1, M2, or M3.
52. Answer: (A) miosis, partial eyelid ptosis, and anhidrosis on the affected
side of the face.
Rationale: Horner's syndrome, which occurs when a lung tumor invades
the ribs and affects the sympathetic nerve ganglia, is characterized by
miosis, partial eyelid ptosis, and anhidrosis on the affected side of the
face. Chest pain, dyspnea, cough, weight loss, and fever are associated
with pleural tumors. Arm and shoulder pain and atrophy of the arm and
hand muscles on the affected side suggest Pancoast's tumor, a lung
tumor involving the first thoracic and eighth cervical nerves within the
brachial plexus. Hoarseness in a client with lung cancer suggests that the
53. Answer: (A) prostate-specific antigen, which is used to screen for prostate
cancer.
Rationale: PSA stands for prostate-specific antigen, which is used to
screen for prostate cancer. The other answers are incorrect.
54. Answer: (D) "Remain supine for the time specified by the physician."
Rationale: The nurse should instruct the client to remain supine for the
time specified by the physician. Local anesthetics used in a subarachnoid
block don't alter the gag reflex. No interactions between local anesthetics
and food occur. Local anesthetics don't cause hematuria.
56. Answer: (B) A fixed nodular mass with dimpling of the overlying skin
Rationale: A fixed nodular mass with dimpling of the overlying skin is
common during late stages of breast cancer. Many women have slightly
asymmetrical breasts. Bloody nipple discharge is a sign of intraductal
papilloma, a benign condition. Multiple firm, round, freely movable masses
that change with the menstrual cycle indicate fibrocystic breasts, a benign
condition.
58. Answer: (D) The client wears a watch and wedding band.
Rationale: During an MRI, the client should wear no metal objects, such
as jewelry, because the strong magnetic field can pull on them, causing
injury to the client and (if they fly off) to others. The client must lie still
during the MRI but can talk to those performing the test by way of the
microphone inside the scanner tunnel. The client should hear thumping
sounds, which are caused by the sound waves thumping on the magnetic
field.
59. Answer: (C) The recommended daily allowance of calcium may be found
in a wide variety of foods.
66. Answer: (C) The cane should be used on the unaffected side
Rationale: A cane should be used on the unaffected side. A client with
osteoarthritis should be encouraged to ambulate with a cane, walker, or
other assistive device as needed; their use takes weight and stress off
joints.
70. Answer: (C) They debride the wound and promote healing by secondary
intention
Rationale: For this client, wet-to-dry dressings are most appropriate
because they clean the foot ulcer by debriding exudate and necrotic
tissue, thus promoting healing by secondary intention. Moist, transparent
dressings contain exudate and provide a moist wound environment.
Hydrocolloid dressings prevent the entrance of microorganisms and
79. Answer: (D) "I'll need to have a C-section if I become pregnant and have
a baby."
Rationale: The human immunodeficiency virus (HIV) is transmitted from
mother to child via the transplacental route, but a Cesarean section
delivery isn't necessary when the mother is HIV-positive. The use of birth
control will prevent the conception of a child who might have HIV. It's true
that a mother who's HIV positive can give birth to a baby who's HIV
negative.
80. Answer: (C) "Avoid sharing such articles as toothbrushes and razors."
Rationale: The human immunodeficiency virus (HIV), which causes
AIDS, is most concentrated in the blood. For this reason, the client
shouldn't share personal articles that may be blood-contaminated, such as
toothbrushes and razors, with other family members. HIV isn't transmitted
by bathing or by eating from plates, utensils, or serving dishes used by a
person with AIDS.
88. Answer: (C) Abnormally low hematocrit (HCT) and hemoglobin (Hb)
levels
Rationale: Low preoperative HCT and Hb levels indicate the client may
require a blood transfusion before surgery. If the HCT and Hb levels
decrease during surgery because of blood loss, the potential need for a
transfusion increases. Possible renal failure is indicated by elevated BUN
or creatinine levels. Urine constituents aren't found in the blood.
Coagulation is determined by the presence of appropriate clotting factors,
not electrolytes.
89. Answer: (A) Platelet count, prothrombin time, and partial thromboplastin
time
Rationale: The diagnosis of DIC is based on the results of laboratory
studies of prothrombin time, platelet count, thrombin time, partial
thromboplastin time, and fibrinogen level as well as client history and other
assessment factors. Blood glucose levels, WBC count, calcium levels, and
potassium levels aren't used to confirm a diagnosis of DIC.
91. Answer: (B) A client with cast on the right leg who states, “I have a funny
feeling in my right leg.”
Rationale: It may indicate neurovascular compromise, requires immediate
assessment.
94. Answer: (D) Use comfort measures and pillows to position the client.
Rationale: Using comfort measures and pillows to position the client is a
non-pharmacological methods of pain relief.
96. Answer: (C) The client holds the cane with his left hand, moves the cane
forward followed by the right leg, and then moves the left leg.
Rationale: The cane acts as a support and aids in weight bearing for the
weaker right leg.
97. Answer: (A) Ask the woman’s family to provide personal items such as
photos or mementos.
Rationale: Photos and mementos provide visual stimulation to reduce
sensory deprivation.
98. Answer: (B) The client lifts the walker, moves it forward 10 inches, and
then takes several small steps forward.
Rationale: A walker needs to be picked up, placed down on all legs.
99. Answer: (C) Isolation from their families and familiar surroundings.
Rationale: Gradual loss of sight, hearing, and taste interferes with normal
functioning.
100. Answer: (A) Encourage the client to perform pursed lip breathing.
Rationale: Purse lip breathing prevents the collapse of lung unit and
helps client control rate and depth of breathing.
3. Answer: (D) Decrease the size and vascularity of the thyroid gland.
Rationale: Lugol’s solution provides iodine, which aids in decreasing the
vascularity of the thyroid gland, which limits the risk of hemorrhage when
surgery is performed.
7. Answer: (B) Keep the irrigating container less than 18 inches above the
stoma.”
Rationale: This height permits the solution to flow slowly with little force
so that excessive peristalsis is not immediately precipitated.
9. Answer:(B) 28 gtt/min
Rationale: This is the correct flow rate; multiply the amount to be infused
(2000 ml) by the drop factor (10) and divide the result by the amount of
time in minutes (12 hours x 60 minutes)
Rationale: The percentage designated for each burned part of the body
using the rule of nines: Head and neck 9%; Right upper extremity 9%; Left
upper extremity 9%; Anterior trunk 18%; Posterior trunk 18%; Right lower
extremity 18%; Left lower extremity 18%; Perineum 1%.
15. Answer: (A) Food and fluids will be withheld for at least 2 hours.
Rationale: Prior to bronchoscopy, the doctors sprays the back of the
throat with anesthetic to minimize the gag reflex and thus facilitate the
insertion of the bronchoscope. Giving the client food and drink after the
procedure without checking on the return of the gag reflex can cause
the client to aspirate. The gag reflex usually returns after two hours.
18. Answer: (A) The left kidney usually is slightly higher than the right one.
Rationale: The left kidney usually is slightly higher than the right one. An
adrenal gland lies atop each kidney. The average kidney measures
approximately 11 cm (4-3/8") long, 5 to 5.8 cm (2" to 2¼") wide, and 2.5
cm (1") thick. The kidneys are located retroperitoneally, in the posterior
aspect of the abdomen, on either side of the vertebral column. They lie
between the 12th thoracic and 3rd lumbar vertebrae.
19. Answer: (C) Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine
6.5 mg/dl.
Rationale: The normal BUN level ranges 8 to 23 mg/dl; the normal serum
creatinine level ranges from 0.7 to 1.5 mg/dl. The test results in option C
are abnormally elevated, reflecting CRF and the kidneys' decreased ability
to remove nonprotein nitrogen waste from the blood. CRF causes
decreased pH and increased hydrogen ions — not vice versa. CRF also
increases serum levels of potassium, magnesium, and phosphorous, and
decreases serum levels of calcium. A uric acid analysis of 3.5 mg/dl falls
within the normal range of 2.7 to 7.7 mg/dl; PSP excretion of 75% also
falls with the normal range of 60% to 75%.
24. Answer: (B) Lying on the left side with knees bent
Rationale: For a colonoscopy, the nurse initially should position the client
on the left side with knees bent. Placing the client on the right side with
legs straight, prone with the torso elevated, or bent over with hands
touching the floor wouldn't allow proper visualization of the large intestine.
25. Answer: (A) Blood supply to the stoma has been interrupted
Rationale: An ileostomy stoma forms as the ileum is brought through the
abdominal wall to the surface skin, creating an artificial opening for waste
elimination. The stoma should appear cherry red, indicating adequate
arterial perfusion. A dusky stoma suggests decreased perfusion, which
may result from interruption of the stoma's blood supply and may lead to
tissue damage or necrosis. A dusky stoma isn't a normal finding. Adjusting
the ostomy bag wouldn't affect stoma color, which depends on blood
supply to the area. An intestinal obstruction also wouldn't change stoma
color.
29. Answer: (C) In long, even, outward, and downward strokes in the
direction of hair growth
Rationale: When applying a topical agent, the nurse should begin at the
midline and use long, even, outward, and downward strokes in the
direction of hair growth. This application pattern reduces the risk of follicle
irritation and skin inflammation.
34. Answer: (C) The emergency department nurse calls up the latest
electrocardiogram results to check the client’s progress
Rationale: The emergency department nurse is no longer directly
involved with the client’s care and thus has no legal right to information
about his present condition. Anyone directly involved in his care (such as
the telemetry nurse and the on-call physician) has the right to information
about his condition. Because the client requested that the nurse update
his wife on his condition, doing so doesn’t breach confidentiality.
37. Answer: (C) Electrocardiogram, complete blood count, testing for occult
blood, comprehensive serum metabolic panel.
Rationale: An electrocardiogram evaluates the complaints of chest pain,
laboratory tests determines anemia, and the stool test for occult blood
determines blood in the stool. Cardiac monitoring, oxygen, and creatine
kinase and lactate dehydrogenase levels are appropriate for a cardiac
primary problem. A basic metabolic panel and alkaline phosphatase and
aspartate aminotransferase levels assess liver function. Prothrombin time,
partial thromboplastin time, fibrinogen and fibrin split products are
50. Answer: (B) “I will call my doctor if Stacy has persistent vomiting and
diarrhea”.
Rationale: Persistent (more than 24 hours) vomiting, anorexia, and
diarrhea are signs of toxicity and the patient should stop the medication
51. Answer: (D) “This is only temporary; Stacy will re-grow new hair in 3-6
months, but may be different in texture”.
Rationale: This is the appropriate response. The nurse should help the
mother how to cope with her own feelings regarding the child’s disease so
as not to affect the child negatively. When the hair grows back, it is still of
the same color and texture.
56. Answer: D 80 mm Hg
Rationale: A client about to go into respiratory arrest will have inefficient
ventilation and will be retaining carbon dioxide. The value expected would
be around 80 mm Hg. All other values are lower than expected.
62. Answer: (C) “I’ll lower the dosage as ordered so the drug causes only 2 to
4 stools a day”.
Rationale: Lactulose is given to a patients with hepatic encephalopathy to
reduce absorption of ammonia in the intestines by binding with ammonia
and promoting more frequent bowel movements. If the patient experience
diarrhea, it indicates over dosage and the nurse must reduce the amount
of medication given to the patient. The stool will be mashy or soft.
Lactulose is also very sweet and may cause cramping and bloating.
63. Answer: (B) Severe lower back pain, decreased blood pressure,
decreased RBC count, increased WBC count.
Rationale: Severe lower back pain indicates an aneurysm rupture,
secondary to pressure being applied within the abdominal cavity. When
ruptured occurs, the pain is constant because it can’t be alleviated until
68. Answer: (D) It inhibits reabsorption of sodium and water in the loop of
Henle.
Rationale: Furosemide is a loop diuretic that inhibits sodium and water
reabsorption in the loop Henle, thereby causing a decrease in blood
pressure. Vasodilators cause dilation of peripheral blood vessels, directly
relaxing vascular smooth muscle and decreasing blood pressure.
Adrenergic blockers decrease sympathetic cardioacceleration and
decrease blood pressure. Angiotensin-converting enzyme inhibitors
decrease blood pressure due to their action on angiotensin.
70. Answer: (C) Narcotics are avoided after a head injury because they may
hide a worsening condition.
Rationale: Narcotics may mask changes in the level of consciousness
that indicate increased ICP and shouldn’t acetaminophen is strong enough
ignores the mother’s question and therefore isn’t appropriate. Aspirin is
contraindicated in conditions that may have bleeding, such as trauma, and
for children or young adults with viral illnesses due to the danger of Reye’s
syndrome. Stronger medications may not necessarily lead to vomiting but
will sedate the client, thereby masking changes in his level of
consciousness.
78. Answer: (A) "I can avoid getting sick by not becoming dehydrated and by
paying attention to my need to urinate, drink, or eat more than usual."
Rationale: Inadequate fluid intake during hyperglycemic episodes often
leads to HHNS. By recognizing the signs of hyperglycemia (polyuria,
polydipsia, and polyphagia) and increasing fluid intake, the client may
prevent HHNS. Drinking a glass of nondiet soda would be appropriate for
hypoglycemia. A client whose diabetes is controlled with oral antidiabetic
agents usually doesn't need to monitor blood glucose levels. A high-
carbohydrate diet would exacerbate the client's condition, particularly if
fluid intake is low.
83. Answer: (C) onset to be at 2:30 p.m. and its peak to be at 4 p.m.
Rationale: Regular insulin, which is a short-acting insulin, has an onset of
15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave the
insulin at 2 p.m., the expected onset would be from 2:15 p.m. to 2:30 p.m.
and the peak from 4 p.m. to 6 p.m.
85. Answer: (B) "Rotate injection sites within the same anatomic region, not
among different regions."
Rationale: The nurse should instruct the client to rotate injection sites
within the same anatomic region. Rotating sites among different regions
may cause excessive day-to-day variations in the blood glucose level;
also, insulin absorption differs from one region to the next. Insulin should
94. Answer: (C) Serous fluids fills the space and consolidates the region
Rationale: Serous fluid fills the space and eventually consolidates,
preventing extensive mediastinal shift of the heart and remaining lung. Air
can’t be left in the space. There’s no gel that can be placed in the pleural
space. The tissue from the other lung can’t cross the mediastinum,
although a temporary mediastinal shift exits until the space is filled.
100. Answer: (D) “I should put on the stockings before getting out of bed in
the morning.
Rationale: Promote venous return by applying external pressure on veins.
4. Answer: (C) Agree to talk with the mother and the father together.
Rationale: By agreeing to talk with both parents, the nurse can
provide emotional support and further assess and validate the family’s
needs.
6. Answer: (D) Suggest that it takes awhile before seeing the results.
Rationale: The client needs a specific response; that it takes 2 to 3
weeks (a delayed effect) until the therapeutic blood level is reached.
11. Answer: (A) By designating times during which the client can focus on
the behavior.
Rationale: The nurse should designate times during which the client can
focus on the compulsive behavior or obsessive thoughts. The nurse
should urge the client to reduce the frequency of the compulsive behavior
gradually, not rapidly. She shouldn't call attention to or try to prevent the
behavior. Trying to prevent the behavior may cause pain and terror in the
client. The nurse should encourage the client to verbalize anxieties to
help distract attention from the compulsive behavior.
12. Answer: (D) Exploring the meaning of the traumatic event with the client.
Rationale: The client with PTSD needs encouragement to examine and
understand the meaning of the traumatic event and consequent losses.
Otherwise, symptoms may worsen and the client may become depressed
or engage in self-destructive behavior such as substance abuse. The
client must explore the meaning of the event and won't heal without this,
no matter how much time passes. Behavioral techniques, such as
relaxation therapy, may help decrease the client's anxiety and induce
sleep. The physician may prescribe antianxiety agents or
antidepressants cautiously to avoid dependence; sleep medication is
rarely appropriate. A special diet isn't indicated unless the client also has
an eating disorder or a nutritional problem.
13. Answer: (C) "Your problem is real but there is no physical basis for it.
We'll work on what is going on in your life to find out why it's happened."
Rationale: The nurse must be honest with the client by telling her that the
paralysis has no physiologic cause while also conveying empathy and
acknowledging that her symptoms are real. The client will benefit from
psychiatric treatment, which will help her understand the underlying cause
of her symptoms. After the psychological conflict is resolved, her
symptoms will disappear. Saying that it must be awful not to be able to
move her legs wouldn't answer the client's question; knowing that the
cause is psychological wouldn't necessarily make her feel better. Telling
her that she has developed paralysis to avoid leaving her parents or that
her personality caused her disorder wouldn't help her understand and
resolve the underlying conflict.
15. Answer: (A) A warning about the drugs delayed therapeutic effect,
which is from 14 to 30 days.
Rationale: The client should be informed that the drug's therapeutic effect
might not be reached for 14 to 30 days. The client must be instructed to
continue taking the drug as directed. Blood level checks aren't necessary.
NMS hasn't been reported with this drug, but tachycardia is frequently
reported.
24. Answer: (C) Set up a strict eating plan for the client.
Rationale: Establishing a consistent eating plan and monitoring the
client’s weight are very important in this disorder. The family and friends
should be included in the client’s care. The client should be monitored
during meals-not given privacy. Exercise must be limited and supervised.
34. Answer: (D) A higher level of anxiety continuing for more than 3
months. Rationale: This is not an expected outcome of a crisis because
by definition a crisis would be resolved in 6 weeks.
40. Answer: (D) Encouraging the client to have blood levels checked as
ordered.
Rationale: Blood levels must be checked monthly or bimonthly when the
client is on maintenance therapy because there is only a small range
between therapeutic and toxic levels.
46. Answer: (D) Males are more likely to use lethal methods than are females
Rationale: This finding is supported by research; females account for 90%
of suicide attempts but males are three times more successful because of
methods used.
47. Answer: (C) "Your cursing is interrupting the activity. Take time out in
your room for 10 minutes."
Rationale: The nurse should set limits on client behavior to ensure a
comfortable environment for all clients. The nurse should accept hostile or
quarrelsome client outbursts within limits without becoming personally
offended, as in option A. Option B is incorrect because it implies that the
client's actions reflect feelings toward the staff instead of the client's own
misery. Judgmental remarks, such as option D, may decrease the client's
self-esteem.
51. Answer: (B) Advising the client to sit up for 1 minute before getting out
of bed.
Rationale: To minimize the effects of amitriptyline-induced orthostatic
hypotension, the nurse should advise the client to sit up for 1 minute
before getting out of bed. Orthostatic hypotension commonly occurs with
tricyclic antidepressant therapy. In these cases, the dosage may be
reduced or the physician may prescribe nortriptyline, another tricyclic
antidepressant. Orthostatic hypotension disappears only when the drug is
discontinued.
56. Answer: (D) It's characterized by an acute onset and lasts hours to
a number of days
Rationale: Delirium has an acute onset and typically can last from
several hours to several days.
58. Answer: (D) This medication may initially cause tiredness, which
should become less bothersome over time.
Rationale: Sedation is a common early adverse effect of imipramine, a
tricyclic antidepressant, and usually decreases as tolerance develops.
Antidepressants aren't habit forming and don't cause physical or
psychological dependence. However, after a long course of high-dose
therapy, the dosage should be decreased gradually to avoid mild
59. Answer: (C) Monitor vital signs, serum electrolyte levels, and acid-
base balance.
Rationale: An anorexic client who requires hospitalization is in poor
physical condition from starvation and may die as a result of arrhythmias,
hypothermia, malnutrition, infection, or cardiac abnormalities secondary to
electrolyte imbalances. Therefore, monitoring the client's vital signs, serum
electrolyte level, and acid base balance is crucial. Option A may worsen
anxiety. Option B is incorrect because a weight obtained after breakfast is
more accurate than one obtained after the evening meal. Option D would
reward the client with attention for not eating and reinforce the control
issues that are central to the underlying psychological problem; also, the
client may record food and fluid intake inaccurately.
72. Answer: (D) Hold the next dose and obtain an order for a stat
serum lithium level
Rationale: Diarrhea and vomiting are manifestations of Lithium toxicity.
The next dose of lithium should be withheld and test is done to validate
the observation. A. The manifestations are not due to drug interaction. B.
Cogentin is used to manage the extra pyramidal symptom side effects of
antipsychotics. C. The common side effects of Lithium are fine hand
tremors, nausea, polyuria and polydipsia.
81. Answer: (D) It promotes emotional support or attention for the client
Rationale: Secondary gain refers to the benefits of the illness that allow
the client to receive emotional support or attention. Primary gain
enables the client to avoid some unpleasant activity. A dysfunctional
family may disregard the real issue, although some conflict is relieved.
Somatoform pain disorder is a preoccupation with pain in the absence of
physical disease.
82. Answer: (A) “I went to the mall with my friends last Saturday”
83. Answer: (A) “I’m sleeping better and don’t have nightmares”
Rationale:MAO inhibitors are used to treat sleep problems, nightmares,
and intrusive daytime thoughts in individual with posttraumatic stress
disorder. MAO inhibitors aren’t used to help control flashbacks or
phobias or to decrease the craving for alcohol.
84. Answer: (D) Stopping the drug can cause withdrawal symptoms
Rationale: Stopping antianxiety drugs such as benzodiazepines can
cause the client to have withdrawal symptoms. Stopping a
benzodiazepine doesn’t tend to cause depression, increase cognitive
abilities, or decrease sleeping difficulties.
86. Answer: (D) It’s a mood disorder similar to major depression but of mild
to moderate severity
Rationale: Dysthymic disorder is a mood disorder similar to major
depression but it remains mild to moderate in severity. Cyclothymic
disorder is a mood disorder characterized by a mood range from
moderate depression to hypomania. Bipolar I disorder is characterized by
a single manic episode with no past major depressive episodes.
Seasonal- affective disorder is a form of depression occurring in the fall
and winter.
90. Answer: (D) The client looks at the shadow on a wall and tells the
nurse she sees frightening faces on the wall.
Rationale: Minor memory problems are distinguished from dementia by
their minor severity and their lack of significant interference with the
client’s social or occupational lifestyle. Other options would be included in
the history data but don’t directly correlate with the client’s lifestyle.
93. Answer: (C) Explain that the drug is less affective if the client smokes
Rationale: Olanzapine (Zyprexa) is less effective for clients who smoke
cigarettes. Serotonin syndrome occurs with clients who take a
combination of antidepressant medications. Olanzapine doesn’t cause
euphoria, and extrapyramidal adverse reactions aren’t a problem.
However, the client should be aware of adverse effects such as tardive
dyskinesia.
95. Answer: (A) “I’m not going to look just at the negative things about
myself” Rationale: As the clients makes progress on improving self-
esteem, self- blame and negative self evaluation will decrease. Clients
with dependent personality disorder tend to feel fragile and inadequate
and would be extremely unlikely to discuss their level of competence and
progress. These clients focus on self and aren’t envious or jealous.
Individuals with dependent personality disorders don’t take over situations
because they see themselves as inept and inadequate.
96. Answer: (C) Assess for possible physical problems such as rash
Rationale: Clients with schizophrenia generally have poor visceral
recognition because they live so fully in their fantasy world. They need
to have as in-depth assessment of physical complaints that may spill
over into their delusional symptoms. Talking with the client won’t provide
as assessment of his itching, and itching isn’t as adverse reaction of
antipsychotic drugs, calling the physician to get the client’s medication
increased doesn’t address his physical complaints.
PRACTICE TEST I
FOUNDATION OF NURSING
1. For the client who is using oral contraceptives, the nurse informs the
client about the need to take the pill at the same time each day to
accomplish which of the following?
a. Decrease the incidence of nausea
b. Maintain hormonal levels
c. Reduce side effects
d. Prevent drug interactions
2. When teaching a client about contraception. Which of the following
would the nurse include as the most effective method for preventing
sexually transmitted infections?
a. Spermicides
b. Diaphragm
c. Condoms
d. Vasectomy
3. When preparing a woman who is 2 days postpartum for discharge,
recommendations for which of the following contraceptive methods
would be avoided?
a. Diaphragm
b. Female condom
c. Oral contraceptives
d. Rhythm method
4. For which of the following clients would the nurse expect that
an intrauterine device would not be recommended?
a. Woman over age 35
b. Nulliparous woman
c. Promiscuous young adult
d. Postpartum client
5. A client in her third trimester tells the nurse, “I’m constipated all the
time!” Which of the following should the nurse recommend?
a. Daily enemas
b. Laxatives
c. Increased fiber intake
d. Decreased fluid intake
6. Which of the following would the nurse use as the basis for the
teaching plan when caring for a pregnant teenager concerned about
gaining too much weight during pregnancy?
a. 10 pounds per trimester
b. 1 pound per week for 40 weeks
c. ½ pound per week for 40 weeks
d. A total gain of 25 to 30 pounds
7. The client tells the nurse that her last menstrual period started on
January 14 and ended on January 20. Using Nagele’s rule, the nurse
determines her EDD to be which of the following?
a. September 27