SUCCEED REVIEW CENTER

NURSING PRACTICE IV
CARE OF THE CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS (PART B)
1. The client with Cushing’s syndrome verbalizes concern to the nurse regarding the appearance of the buffalo hump that
has developed. Which statement by the nurse is appropriate?
1. “This is permanent, but looks are deceiving and are not that important.”
2. “Don’t be concerned; this problem can be covered with clothing.”
3. “Try not to worry about it; there are other things to be concerned about.”
4. “Usually these physical changes slowly improve following treatment.”
Correct Answer: 4
Rationale:
The client with Cushing’s syndrome should be reassured that most physical changes resolve with treatment. Options 1
2, and 3 are not therapeutic responses.
2. Corticosteroids can cause infections. Which rationale does not support this concept? Corticosteroids:
1. Prevent the production of leukocytes
2. Stop antibody production in lymphatic tissue
3. Promote the growth and spread of enteric viruses
4. Interfere with the inflammatory response of the body
Answer 3
Raonale 1. Immunosuppressant action causes bone marrow depression, which decreases the number of WBC5.
Rationale 2. They interfere with antibody production.
Rationale 3. These agents are classified as antiinflammatory or immunosuppressive. Glucocorticoids interfere with the body’s
response to microorganisms but do not directly promote the spread of enteroviruses.
Rationale 4. They interfere with the release of enzymes responsible for the inflammatory response.
3. Corticosteroids can cause infections. Which rationale does not support this
concept? Corticosteroids:
1. Prevent the production of leukocytes
2. Stop antibody production in lymphatic tissue
3. Promote the growth and spread of enteric viruses
4. Interfere with the inflammatory response of the body
Answer 3
Raonale 1. Immunosuppressant action causes bone marrow depression, which
decreases the number of WBC5.
Rationale 2. They interfere with antibody production.
Rationale 3. These agents are classified as antiinflammatory or immunosuppressive. Glucocorticoids interfere with the body’s
response to microorganisms but do not directly promote the spread of enteroviruses.
Rationale 4. They interfere with the release of enzymes responsible for the inflammatory response.
4. A client’s blood gases reflect diabetic acidosis. Which clinical indicator should the
nurse expect to identify when monitoring this client’s laboratory values?
1. Increased pH
2. Decreased PC2
3. Increased PCO2
4. Decreased HCO
Answer 4
Rationale 1. The pH is decreased.
Rationale 2. The PC2 is not decreased in diabetic acidosis.
Rationale 3. The PCO2 may be decreased by the body’s attempt to eliminate CO2 to compensate for a low pH.
Rationale 4. The bicarbonate-carbonic acid buffer system helps maintain the pH of body fluids: in metabolic aciclosis there is a
decrease in bicarbonate because of an increase of metabolic acids.
5. On the first postoperative day following a thyroidectomy. a client tolerates a full- fluid diet. This is changed to a soft diet on
the second postoperative day. The client complains of a sore throat when swallowing. What should the nurse do?
1. Reorder the full-fluid diet.
2. Notify the physician immediately.
3. Administer analgesics as prescribed before meals.
4. Provide saline gargles to moisten the mucous membranes.
Answer 3
Rationale 1.This is not a nursing function.
Rationale 2. Soreness is to be expected: this is not an emergency necessitating medical action.
Rationale 3. Soreness is to be expected. A progression to a soft diet will provide nutnents needed for healing and energy and
will stimulate the return of bowel activity. Analgesics as ordered will reduce soreness during meals.
Rationale 4. The soreness is not because of drying: when the client is at home. humidified air might help reduce the soreness,
but it would not help the client eat the soft diet.
6. The nurse is caring for a client after thyroidectomy. The nurse notes that calcium gluconate is prescribed for the client.
The nurse determines that this medication has been prescribed to:
1. Treat thyroid storm.
2. Prevent cardiac irritability.
3. Stimulate release of parathyroid hormone.
4. Treat hypocalcemic tetany.
Correct Answer: 4
Rationale:
Hypocalcemia can develop after thyroidectomy if the parathyroid glands are accidentally removed during surgery.
Manifestations develop 1 to 7 days after surgery. If the client develops numbness and tingling around the mouth, fingertips, or
toes; muscle spasms; or twitching, the physician is notified immediately. Calcium gluconate should be kept at the bedside.
7. Understanding the need to decrease the size and vascularity of the thyroid gland before a thyroidectomy. which medication
can the nurse expect the physician to order?
1. Pitressin
2. Propylthiouracil
3. Potassium iodide
4. Potassium permanganate
Answer 3
Rationale 1. This is an antidiuretic hormone.
Rationale 2. This drug interferes with production of thyroid hormone but causes increased vascularity and size of the thyroid.
Rationale 3. This adds iodine to the body fluids, exerting negative feedback on the thyroid tissue and decreasing its
metabolism and vasculanty.
Rationale 4. This is a topical antiseptic.
8. When taking the blood pressure of a client who has had a thyroidectomy. the nurse notices the client is pale and has
spasms of the hand The nurse notifies the physician. While awaiting the physician’s orders, the nurse should prepare for
replacement of:
1. Calcium
2. Magnesium
3. Bicarbonate
4. Potassium chlonde
Answer 1
Rationale 1. These signs may indicate calcium depletion as a result of accidental removal of parathyroici glands dunng
thyroidectomy.
Rationale 2. Symptoms associated with hypomagnesemia include tremor,
neuromuscular irritability, and confusion.
Rationale 3. Symptoms associated with metabolic acidosis include deep. rapid breathing. weakness, and disorientation.
Rationale 4. Symptoms associated with hypokalemia include muscle weakness and dysrhythmias.
9. A client has a hypoglycemic reaction to insulin. When the nurse assesses this client, which adaptation is indicative of this
response?
1. Glycosuna
2. Perspiration
3. Dry, hot skin
4. Fruity odor of breath
Answer 2
Rationale 1. Because blood glucose level is low, the renal threshold is not exceeded. and there is no glycosuria.
Rationale 2. Because the brain requires a constant supply of glucose, hypoglycemia tnggers the response of the sympathetic
nervous system. which causes this sign. Rationale 3. This is consistent with dehydration, which is often associated with
hypergtycemic states.
Rationale 4. This is associated with hyperglycemia: it is caused by the breakdown of fats as a result of inadequate insulin
supply.
10. The nurse is caring for a client who had a hypophysectomy. The nurse specifically should observe this client for an early
clinical indicator of:
1. Urinary retention
2. Respiratory distress
3. Bleeding at the suture line
4. Increased intracranial pressure
Answer 4
Rationale 1. This may follow any surgery because of the effects of anesthesia and is not a specific occurrence following cranial
surgery.
Rationale 2. This is not an initial sign of increased intracranial pressure. This may be the result of pressure on the medulla
caused by increased intracranial pressure. Rationale 3. This may occur with any surgery, not just a hypophysectomy.
Rationale 4. Because the pituitary gland is located in the brain, edema afler surgery may result in increased intracranial
pressure.
11. When assessing for complications of hyperparathyroiclism. the nurse should monitor the client for which response?
1. Tetany
2. Seizures
3. Graves’ disease
4. Bone destruction
Answer 4
Rationale 1. Tetany is the result of low calcium levels: in this condition serum calcium level is high.
Rationale 2. Seizures are caused by increased neural activity, a condition not related to this disease.
Rationale 3. Graves’ disease is the result of increased thyroid. not parathyroid. activity.
Rationale 4. Hyperparathyroidism causes calcium release from the bones, leaving them porous and weak.
12. A client admitted to the emergency department has ketones in the blood and urine Which situation associated with this
development should be the nurse’s focus when collecting additional data about this client?
1. Starvation
2. Alcoholism
3. Bone healing
4. Positive nitrogen balance
Answer I
Rationale 1. In starvation there are inadequate carbohydrates available for immediate
energy and stored fats are used in excessive amounts, producing ketones.
Rationale 2. There is no fat in alcohol: no fat oxidation occurs.
Rationale 3. This does not require the use of great amounts of fat: calcium is
deposited to form callus.
Rationale 4. This does not require the use of great amounts of fat.
13. A client tells the nurse during the admission history that an oral hypoglycemic agent is a medication that is taken daily. The
nurse understands that an oral hypoglycemic agent may be used for clients with:
1. Ketosis
2. Obesity
3. Type 1 diabetes
4. Some insulin production
Answer 4
Rationale 1. Rapid-acting regular insulin is needed to reverse ketoacidosis.
Rationale 2. Obesity does not offer enough information to determine the status of beta cell function.
Rationale 3. Clients with type 1 diabetes have no functioning beta cells
Rabonale 4. Oral hypoglycemics may be helpful when some functioning of the beta cells exists, as En type 2 diabetes.
14. The nurse is caring for a client who just had a thyroidectomy. Because an accidental removal of the parathyroid glands
during a thyroidectomy is always a concern, for which client response should the nurse assess?
1. Tetany
2. Myxeclema
3. Hypovolemic shock
4.Adrenocortical stimulation
Answer I
Rationale I. Parathyroid removal eliminates the body’s source of parathyroid hormone (parathormone), which increases blood
calcium level. The resulting low body fluid calcium affects muscles, including the diaphragm. resulting in dyspnea. asphyxia.
and death.
Rationale 2. Loss of the thyroid gland would upset thyroid hormone balance and might cause myxedema.
Rationale 3. The parathyroids are not involved in regulating plasma volume: the pituitary and adrenal glands are responsible.
Rationale 4. The parathyroids do not regulate the adrenal glands.
15. After assessing a client, the nurse concludes that the client may be experiencing hyperglycemia. Which clinical indicator
commonly associated with hyperglycemia supports the nurse’s conclusion?
1. Polydipsia
2. Polyphasia
3. Polygalactia
4. Polydyspasia
Answer I
Rationale 1. This is excessive thirst associated with hyperglycemia: thirst is the
response to osmotic diuresis and glycosuria.
Rationale 2. This is excessive talking associated with mental illness, not
hyperglycemia.
Rationale 3. This is the excessive secretion of milk and is unrelated to hyperglycemia.
Rationale 4. This is when a person has multiple developmental abnormalities and is unrelated to hyperglycemia.
16. The nurse should monitor a client with Addison’s disease closely for signs of infectious complications because there is a
disturbance in which bcxly mechanism? 1. Stress response
2. Electrolyte balance
3. Metabolic processes
4. Respiratory function
Answer 1
Rationale 1. Because of diminished glucocorticoid production. there is a decreased response to stress, reducing the ability to
fight an infectious process.
Raonale 2. Hyponatremia and hyperkalemia occur in this disorder: however, these do not alter the defense against infection.
Raonale 3. Glucocorticoids are involved with metabolism: however, this does not directly affect susceptibility to infection.
Rationale 4. The respiratory system is not affected.
17. The physician orders a low-sodium, high-potassium diet for a client with Cushing’s syndrome. The nurse understands that
this diet was ordered for this client because
1. The use of salt probably contributed to the disease
2. Excess weight will be gained if sodium is not limited
3. The loss of excess salt in the urine requires less renal stimulation
4. Excessive secretions of aldosterone and cortisone cause renal retention of sodium and loss of potassium
Answer 4
Rationale 1. An excessive secretion of adrenocortical hormones in Cushing’s syndrome. not increased or high sodium intake, is
the problem.
Rabonale 2. Although sodium retention causes fluid retention and weight gain, the need for increased potassium must also be
considered.
Rationale 3. Because of steroid therapy, excess sodium may be retained rather than excreted.
Rationale 4. Clients with Cushing’s syndrome must limit their intake of salt and increase their intake of potassium. The kidneys
are retaining sodium and excreting potassium.
18. A urine specimen is needed to test for the presence of ketones in a client who is diabetic. What should the nurse do when
collecting this specimen from a urinary retention catheter?
1. Disconnect the catheter and drain the urine into a clean container.
2. Clean the drainage valve and remove the urine from the catheter bag.
3. Wipe the catheter with alcohol and drain the urine into a sterile test tube.
4. Use a sterile syringe to remove the urine from a clamped, cleansed catheter.
Answer 4
Rabonale 1. The system should remain closed so that fewer microorganisms enter the
urinary system.
Rationale 2. This would not yield a fresh specimen indicating present acetone levels.
Rationale 3. The system should remain closed so that fewer microorganisms enter the urinary system.
Rationale 4. The urinary catheter and drainage bag should always remain a closed sterile system: urine should be drawn only
from the catheter, not the collection bag.
19. A urine specimen is needed to test for the presence of ketones in a client who is diabetic. What should the nurse do when
collecting this specimen from a urinary retention catheter?
1. Disconnect the catheter and drain the urine into a clean container.
2. Clean the drainage valve and remove the urine from the catheter bag.
3. Wipe the catheter with alcohol and drain the urine into a sterile test tube.
4. Use a sterile syringe to remove the urine from a clamped, cleansed catheter.
Answer 4
Rabonale 1. The system should remain closed so that fewer microorganisms enter the
urinary system.
Rationale 2. This would not yield a fresh specimen indicating present acetone levels.
Rationale 3. The system should remain closed so that fewer microorganisms enter the urinary system.
Rationale 4. The urinary catheter and drainage bag should always remain a closed sterile system: urine should be drawn only
from the catheter, not the collection bag.
20. A client with diabetes is given instructions about foot care Which client statement
indicates an understanding of the nurse’s instructions? “I will:
1. Soak my feet daily for 1 hour.1’
2. Cut my toenails before bathing.”
3. Examine my feet using a mirror at least once a week”
4. Break in new shoes over the course of several weeks.”
Answer 4
Rationale 1. This will cause maceration of the skin and should be avoided.
Rationale 2. The toenails should be cut by a podiatrist: they usually are cut after soaking, when the nails are softer.
Rationale 3. This is too long a period of time: the client should examine the feet daily for signs of trauma
Rationale 4. A slower, longer period of time to break in new, stiff shoes will help prevent blisters and skin breakdown.
21. A client with diabetes mellitus has an above-the-knee amputation because of severe peripheral vascular disease. Which is
the nurse’s primary responsibility 2 days following surgery when prepanng the client for dinner?
1. Checking the client’s serum glucose level
2. Assisting the client out of bed into a chair
3. Placing the client in the high-Fowlers position
4. Ensuring that the client’s residual limb is elevated
Answer I
Rationale 1. Because the client has severe diabetes, it is essential that the blood glucose level be determined before meals to
evaluate the level of control of diabetes and the possible need for insulin coverage.
Rationale 2. To prevent flexion contractures of the hip. the client should not sit for a prolonged time.
Rationale 3. Raising the head of the bed flexes the hips, which could result in hip flexion contractures.
Rationale 4. This could result in a hip flexion contracture.
22. The nurse is caring for two clients newly diagnosed with diabetes mellitus. One client has type 1 diabetes and the other
client has type 2 diabetes. The nurse understands that the main difference between newly diagnosed type 1 and type 2
diabetes mellitus is that in type 1 diabetes:
1. Onset of the disease is slow
2. Excessive weight is a contributing factor
3. Treatment involves diet, exercise, and oral agents
4. Complications are not present at time of diagnosis
Answer 4
Rationale 1. Clinical presentation of type 1 diabetes is rapid. not slow, as pancreatic beta cells are destroyed by an
autoimmune process in type 2 diabetes, the body is still producing some insulin, and therefore the onset of signs and
symptoms is slow.
Rationale 2. In type I diabetes. clients are generally lean or have an ideal weight:
80% to 90% of clients with type 2 diabetes are overweight.
Rationale 3. Type 1 diabetes requires diet control. exercise. and subcutaneous administration of insulin, not oral agents: oral
agents are used in type 2 diabetes when some insulin is still being produced.
Rationale 4. Clinical presentation of type 1 diabetes is characterized by acute onset and therefore there is no time to develop
the long-term complications that are common with long-standing disease: 20% of newly diagnosed clients with type 2
diabetes demonstrate complications because the diabetes has gone undetected for an extended period of time.
23. The nurse is assessing a client with Cushing’s syndrome. Which clinical indicator
can the nurse expect to identify?
1. Menorrhagia
2. Buffalo hump
3. Dependent edema
4. Migraine headaches
Answer 2
Rationale 1. Menorrflagia (excessive menstrual bleeding) does not occur: menses
may cease or be scanty because of vinhization.
Rationale 2. Cushing’s syndrome results from excess adrenocortical activity. Hypercortisolism causes fat redistribution,
resulting in ‘buffalo hump”: it also contributes to slow wound healing. hirsutism. weight gain. hypertension. acne. moon face,
thin arms and legs, and behavioral changes.
Rationale 3. Edema does not occur except when heart failure is present and severe.
Rationale 4. Headaches are not caused by this syndrome.
24. A client is diagnosed with diabetes insipidus. During assessment. which sign does
the nurse identify as the most indicative of diabetes insipidus?
1. Increased blood glucose
2. Decreased serum osmolarity
3. Elevation of blood pressure
4. Low urinary specific gravity
Answer 4
Raonale 1. Diabetes insipidus is not a disorder of glucose metabolism: blood glucose
levels are not affected.
Rationale 2. As fluid is lost from the vascular compartment. serum osmolanty
increases.
Rationale 3. Loss of fluid may actually lower blood pressure.
Rationale 4. Because water is not being reabsorbed. urine is dilute, resulting in a low specific gravity.
25. Which piece of information from the clienUs history does the nurse identity as a risk
factor for developing osteoporosis? The client:
1. Receives long-term steroid therapy
2. Has a history of hypoparathyroidism
3. Engages in strenuous physical activity
4. Consumes high doses of the hormone estrogen
Answer 1
Rationale 1. Increased levels of steroids will accelerate bone demineralization.
Rationale 2. Hyperparathyroidism. not hypoparathyroidism. accelerates bone demineralization.
Rationale 3. Weight-bearing that occurs with strenuous activity promotes bone integrity by preventing bone demineralization.

Rationale 4. Although estrogen promotes deposition of calcium into bone. high levels would not be prescribed for
osteoporosis hormone replacement therapy is associated with an increased risk for cancer of the breast.
26.The nurse is caring for a client admitted to the emergency department after taking an overdose of morphine sulfate (MS
Contin). The nurse should give priority to monitoring the client for:
A. Decreased urinary output
B. Nausea and vomiting
C. Respiratory depression
D. Increased blood pressure
150. Answer C is correct. MS Contin is capable of producing severe or fatal respiratory depression. Answers A and B do not
take priority over the client’s respiratory status; therefore, they are incorrect. Answer D is incorrect because the blood
pressure would be decreased, not increased.
27. 154. The nurse is rendering first aid at the scene of a motor vehicle accident. Before moving a client with an apparent
fracture of lower leg, the nurse should give priority to:
A. Removing the client’s shoes to see whether there is trauma to the foot
B. Immobilizing the extremity by splinting the joint above and below the fracture
C. Keeping the client in a semi-sitting position
D. Checking the neurovascular status of the area distal to the fracture
154. Answer B is correct. The joint above and below a fracture should be immobilized before the client is moved to prevent
further damage to the soft tissue, nerves, and blood vessels. Answer A is incorrect because removing the shoe can result in
movement and further trauma. Answer C is incorrect because the client should lie down, not sit up. Answer D is incorrect
because it is not necessary before moving the client.
28. 155. Which nursing diagnosis should receive priority when the nurse is caring for a client with esophageal varices?
A. Imbalanced nutrition: less than body requirements related to difficulty swallowing
B. High risk for injury related to altered clotting mechanisms
C. Fluid volume deficit related to reduced oral intake
D. Activity intolerance related to fatigue
155. Answer B is correct. The client with esophageal varices has a high risk of injury and bleeding from dilated esophageal
blood vessels and altered clotting mechanisms. Answers A, C, and D are incorrect because they do not take priority over
the client’s risk for injury and bleeding.
29. 156. Using the coding system for triaging mass casualties, which of the following clients
would receive treatment first?
A. The client with a black tag
B. The client with a green tag
C. The client with a yellow tag
D. The client with a red tag
156. Answer D is correct. The client with a red tag is classified as emergent or Class 1.
Answer A is incorrect because the client is classified as expectant or Class 4.
Answer B is incorrect because the client is classified as non-urgent or Class 3.
Answer C is incorrect because the client is classified as urgent or Class 2.
30. 161. The nurse is caring for a client with organophosphate poisoning that has produced symptoms of cholinergic crisis. The
nurse should prepare to administer:
A. Adrenalin
B. Vasopressin
C. Atropine
D. Lithium
161. Answer C is correct. The nurse should prepare to administer atropine since it is the treatment for cholinergic crisis.
Answers A, B, and D are not used in the treatment of cholinergic crisis; therefore, they are incorrect choices.
31. 162. Which one of the following clients is at greatest risk for developing heat exhaustion?
A. A 17-year-old skateboarder
B. A 30-year-old electrical worker
C. A 45-year-old landscaper
D. A 65-year-old farmer
162. Answer D is correct. Older adults are at greatest risk for developing heat exhaustion. Answers A, B, and C are not as likely
to develop heat exhaustion as the older client; therefore, they are incorrect choices.
32. 163. Which one of the following clients falls into the category of emergent care?
A. A client admitted with a simple fracture of the arm
B. A client admitted with abdominal pain
C. A client admitted with chest pain, dyspnea, and diaphoresis
D. A client admitted with a cough and temp of 101° F
163. Answer C is correct. The client’s symptoms suggest a possible myocardial infarction; therefore, the client is classified as
emergent. The client with a simple fracture is classified as non-urgent, so Answer A is incorrect. The client with abdominal
pain is classified as urgent; therefore, Answer B is incorrect. The client with a cough and temp of 101° F is classified as urgent;
therefore, Answer D is incorrect.
33. 164. A client with a history of myasthenia gravis is admitted with signs of a myasthenic crisis. Emergency interventions for
the client with a myasthenic crisis focus on:
A. Administering diphenhydramine
B. Maintaining adequate respiratory function
C. Assessing the degree of muscle weakness
D. Administering atropine sulphate
164. Answer B is correct. Priority should be given to maintaining the client’s respiratory function. Answers A and D are
incorrect because the medications are not used in the treatment of myasthenic crisis. Answer C is incorrect because it does
not take priority over assessment of the client’s respiratory function.
34. Aclient is admitted with a fracture of the neck of the femur. In what position should the nurse maintain the client’s
affected extremity?
1. Internal rotation with extension of the knee and hip
2. Internal rotation with flexion of the knee and hip
3. External rotation with flexion of the knee and hip
4. External rotation with extension of the knee and hip
Answer 1
Rationale i.Afracture in the neck of the femur will cause shortening of the femur and external rotation. To correct this
misalignment, the clients leg should be extended and maintained in slight internal rotation.
Rationale 2. To reduce the fracture. it is necessary to maintain the leg in extension. counteracting the contraction of the
quadriceps that may cause overriding of bone fragments.
Rationale 3. To reduce the fracture. it is necessary to maintain the leg in extension. counteracting the contraction of the
quadriceps that may cause overriding of bone fragments.
Rationale 4. External rotation of the thigh as a result of muscle contraction tends to misalign the bone fragments therefore
slight internal rotation or functional alignment is preferred.
35. What does the nurse understand that clients with myasthenia gravis, Guillain-Barré
syndrome. and amyotrophic lateral sclerosis share in common?
1. Progressive deterioration until death
2. Deficiencies of essential neurotransmitters
3. Increased risk for respiratory complications
4. Involuntary twitching of small muscle groups
Answer 3
Raonale 1. Although ALS is progressive, clients with myasthenia gravis may be stable with treatment and clients with Guillain-
Barré syndrome may experience a complete recovery.
Rabonale 2. None of these diseases are caused by a lack of neurotransmitters: only myasthenia gravis is associated with a
decreased number of receptor sites.
Rationale 3. As a result of muscle weakness, the vital capacity is reduced, leading to increased risks of respiratory
complications: impaired swallowing can also lead to aspiration.
Rationale 4. Twitching is not expected with myasthenia gravis or Guillain-Barré syndrome.
36. A client is diagnosed with Parkinson’s disease and asks the nurse what causes the
disease. On which underlying pathology does the nurse base a response?
1. Disintegration of the myelin sheath
2. Breakdown of the corpora quad ngemina
3. Reduced acetyicholine receptors at synapses
4. Degeneration of the neurons of the basal ganglia
Answer 4
Rationale 1. This pathologic condition is associated with multiple sclerosis.
Rationale 2. This condition would result in auditory and visual problems it is not
associated with Parkinson’s disease.
Rationale 3. This condition is associated with myasthenia gravis.
Rationale 4. Parkinson’s disease involves destruction of the neurons of the substantia nigra. caudate nucleus, and globus
pallidus of the basal ganglia. The cause of this destruction is unknown.

37. After a client has cataract surgery, what should the nurse do?
1. Instruct the client to avoid driving for 2 weeks.
2. Teach the client coughing and deep-breathing techniques.
3. Encourage eye exercises to strengthen the ocular musculature.
4. Advise the client to refrain from vigorous brushing of teeth and hair.
Answer 4
Rationale 1. This is unnecessary: clients are usually permitted to drive before this
time.
Rationale 2. Coughing and deep breathing can increase intraocular pressure.
Rationale 3. Weakening of the eye musculature is not related to cataracts.
Rationale 4. Activities such as rigorous brushing of hair and teeth cause increased intraocular pressure and may lead to
hemorrhage in the anterior chamber.
38. A client has a long leg cast. What instructions should the nurse give the client in
preparation for crutch walking?
1. Use the trapeze to strengthen the biceps.
2. Keep the affected limb in extension and abduction.
3. Sit up straight in a chair to develop the back muscles.
4. Do exercises in bed to strengthen the upper extremities.
Answer 4
Rationale 1. This activity does not strengthen muscles used in crutch-walking.
Rationale 2. Keeping the leg in abduction alters the center of gravity, which impedes
ambulation.
Rationale 3. Back muscles are not used in crutch-walking.
Rationale 4. In crutch-walking the client uses the triceps. trapezius. and latissimus muscles. A client who has been in bed may
need to implement an exercise program to strengthen these shoulder and upper arm muscles before initiating crutch-
walking.
39. Which statement by a client with multiple sclerosis indicates to the nurse that the client needs further teaching’?
1. “I use a straw to drink liquids”
2. ‘I will take a hot bath to help relax my muscles.”
3. I plan to use an incontinence pad when I go out.”
4. “I may be having a rough time now, but I hope tomorrow will be better.”
Answer 2
Rationale 1. Using a straw gives the client more control of liquid intake, preventing aspiration.
Rationale 2. This tends to increase symptoms and may result in burns because of decreased sensation.
Rationale 3. Although a bladder regimen to maintain control is preferable. the use of pads can avoid embarrassment.
Rationale 4. The disease does have periods of remission and exacerbation.
40. A client with myasthenia gravis has been receiving neostigmine (Prostigmin). What understanding of its action should the
nurse have before administering this drug’? 1. Stimulates the cerebral cortex.
2. Blocks the action of cholinesterase.
3. Replaces deficient neurotransmitters.
4. Accelerates transmission along neural sheaths.
Answer 2
Rationale 1. Neostigmines action is at the myoneural junction. not the cerebral cortex.
Rationale 2. Neostigmine. an anticholinesterase. inhibits the breakdown of ACh. thus prolonging neurotransmission.
Rationale 3. Neostigmine prevents neurotransmitter breakdown but is not a neurotransmitter.
Rationale 4. Neostigmines action is at the myoneural junction, not the sheath.
41. A client with degenerative joint disease asks the nurse. “My doctor mentioned something about synovial fluid and the
joint. What is that?” What is the nurse’s best response? “The synovial fluid of the joints minimizes:
1. Efficiency.”
2. Work output.”
3. Friction in the joints.”
4. Velocity of movements.”
Answer 3
Rationale 1. Synovial fluid increases the efficiency of joint movements.
Rationale 2. Synovial fluid increases work output.
Rationale 3. Synovial fluid minimizes friction at joints by providing lubrication for the moving parts.
Rationale 4. Synovial fluid increases the speed of movements.
42. After a client experiences a spinal cord injury, the nurse encourages the client to
drink fluids primarily to prevent:
1. Dehydration
2. Skin breakdown
3. Electrolyte imbalances
4. Urinary tract infections
Answer 4
Raonale 1. Dehydration is not a major problem after spinal cord injury.
Rationale 2. Pressure-relieving devices and interventions are most essential in
preventing skin breakdown.
Rationale 3. An electrolyte imbalance is not a major problem after spinal cord injury.
Rationale 4. Clients in the early stages of spinal cord damage experience an atonic bladder, which is characterized by the
absence of muscle tone, an enlarged capacity, no feeling of discomfort with distention, and overflow with a large residual. This
leads to urinary stasis and infection. High fluid intake limits urinary stasis and infection by diluting the urine and increasing
urinary output.
43. When placing a client with a fractured hip in traction before surgery. the nurse
explains that the purpose of traction is to:
1. Relieve muscle spasm and pain
2. Prevent contractures from developing
3. Keep the client from turning and moving in bed
4. Maintain the limb in a position of external rotation
Answer 1
Rationale 1. Traction is frequently used in the treatment of a fractured hip to align the bones (reduction of fracture). If such
traction were not employed, the muscles would go into spasm. shifting the bone fragments and causing pain.
Rationale 2. Traction is usually a temporary measure before surgery: contractures result from a shortening of the muscles by
prolonged immobility.
Rabonale 3. Although the affected extremity must be properly aligned, turning and moving the client is still necessary.
Rationale 4. External rotation is contraindicated and prevented by the use of sandbags or trochanter rolls.
44. A client is scheduled for surgery for a detached retina Which client statement indicates to the nurse that preoperative
teaching is effective? “The goal of surgery is to:
1. Promote growth of new retinal cells.”
2.Adhere the sciera to the choroid layer.”
3. Graft a healthy piece of retina in place.”
4. Create a scar that aids in healing retinal holes.”
Answer 4
Raonale 1. The retina is part of the nervous system: it does not regenerate or grow new cells.
Rationale 2. The Sc (era is not involved: the retina adjoins and is nourished by the choroici.
Rationale 3. This is not the treatment used: treatment includes the formation of a scar by the use of lasers or surgical
“buckling.”
Rationale 4. Scar formation seals the hole and promotes attachment of the two retinal surfaces.
45. 1. Ondansetron (Zofran) is administered to the patient receiving chemotherapy to:
A. prevent nausea and vomiting.
B. promote a feeling of well-being.
C. increase effectiveness of therapy.
D. improve renal function.
1. (A); Ondansetron (Zofran) is an antiemetic medication used in conjunction with
chemotherapy to prevent nausea and vomiting.
46. 2. The nurse is caring for a patient who will receive external radiation therapy. The
patient asks the nurse why the ugly ink marks and tattoos over the area to be
radiated are necessary. The best response by the nurse is:
A. “The markings indicate where the technician should focus treatments.”
B. “The markings let you know the exact location of your cancer.”
C. “Exact markings are critical to limit damage to healthy tissues.”
D. “Exact markings indicate potentially salvageable tissue.”
2. (C); The nurse understands that external radiation provides targeted treatment to the
area of the body affected by cancer. Exact markings are critical to limit damage to
healthy tissues during treatment.
47. 3. The nurse is caring for a patient who is receiving interleukins for treatment of renal cell carcinoma. For which of the
following conditions must the nurse monitor the patient during treatment?
A. capillary leak syndrome
B. acute respiratory distress syndrome
C. hypertension
D. decreased cardiac output
3. (A); The nurse must monitor the patient for capillary leak syndrome related to interleukin therapy for cancer. Capillary leak
syndrome is manifested by generalized edema, decreased urine output, and hypotension.
48. When interviewing a client with a tentative diagnosis of Parkinson’s disease. the nurse expects the client to report the
onset of symptoms occurred:
1. Suddenly
2. Overnight
3. Gradually
4. Irregularly
Answer 3
Rationale 1. The onset is slow and gradual.
Rabonale 2. The onset is slow and gradual.
Rationale 3. The onset of this disease is not sudden. but insidious, with a prolonged course and gradual progression.
Rationale 4. The onset is not irregular: there is a gradual, regular progression of symptoms.
49. When developing a teaching plan for a client with trigeminal neuralgia. the nurse should include an explanation of the side
effects of which medication typically used to treat this disorder?
1.Ascorbic acid
2. Morphine sulfate
3. Allopunnol (Zyloprim)
4. Carbamazepine (Tegretol)
Answer 4
Rationale 1. Ascorbic acid (vitamin C) may be used as an adjunct to the specific treatment for trigeminal neuralgia. Vitamin C is
prescribed when the body is subject to stress, as occurs with pain.
Rationale 2. Morphine is an opioid analgesic that will relieve severe pain but will not prevent its recurrence prolonged
frequent use is contraindicated because of possible addiction.
Rationale 3. Allopunnol is used in the treatment of gout.
Rationale 4. Carbamazepine (Tegretol) is a nonnarcotic analgesic. anticonvulsive drug used to control pain in tngeminal
neuralgia and to abort future attacks. It sometimes eliminates the need for surgery.
50. A community health nurse who is conducting a teaching session about the risks of testicular cancer has reviewed a list
of instructions regarding testicular self-examination (TSE) with the clients attending the session. Which statement by a
client indicates a need for further instruction?
1. “TSE is performed once a month.”
2. “TSE should be performed on the same day of each month.’
3. “The scrotum is held in one hand and the testicle is rolled between the thumb and forefinger of the other hand.”
4. “It is best to do TSE first thing in the morning before a bath or shower.”
Correct Answer: 4
Rationale:
TSE is performed once a month and should be done on the same day of each month, as an aid to help the client remember to
perform the exam. The scrotum is held in one hand and the testicle is rolled between the thumb and forefinger of the other
hand. It is best to perform the exam during or after a warm shower or bath when the scrotum is most relaxed.
51. A female client is very upset with her diagnosis of gonorrhea and asks the nurse. “What can I do to prevent getting another
infection in the future?” The nurse is aware that the teaching has been understood when the client states, “My best
protection is to
A. Douche after every intercourse”
B. Avoid engaging in sexual behavior.”
C. Insist that my partner use a condom”
D. Use a spermicidal cream with intercourse.”
Answer C
Rationale A. This has no proven protective effect against sexually transmitted infections: excessive douching can alter the
vaginal environment and may promote an ascending infection
Rationale B. This is not the most realistic response to a sexually active person.
Rationale C. Once people become sexually active, they usually remain sexually active: a condom, although not 100% effective,
is the best protection against gonorrhea in a sexually active person.
Rationale D. Spermicidal cream has no protective effect against sexually transmitted infections.
52. The nurse is planning to provide discharge teaching to the family of a client with AIDS. Which statement should the nurse
include in the teaching plan?
A. “Wash the dishes in hot soapy water as you usually do.”
B. “Let the dishes soak in hot water overnight before washing”
C. “You should boil the clienVs dishes for 30 minutes after use.”
D. “Have the client eat from paper plates so they can be discarded.”
Answer 3
Rationale A. This is unnecessary.
Rationale B. This is unnecessary.
Rationale C. A person cannot contract HIV by eating from dishes previously used by an individual with AlDS routine care is
adequate
Rationale D. This is unnecessary.
53. A client is admitted with the diagnosis of tetanus It is most important for the nurse to observe for which clinical indicator?
A. Muscular rigidity
B. Respiratory tract spasms
C. Restlessness and irritability
D. Spastic voluntary muscle contractions
Answer 2
Rationale 1. This generalized condition is not life threatening.
Rationale 2. Toxins from the bacillus invade nervous tissue: respiratory spasms may result in respiratory failure.
Rationale 3. This generalized condition is not life threatening.
Rationale 4. This generalized condition is not life threatening.
54. A client is diagnosed as having gonorrhea. What medication should the nurse expect the physician to order?
A. Acyclovir (Zovirax)
B. Colistin (Cortisporin)
C. Cettriaxone (Rocephin)
D. Dactinomycin (actinomycin)
Answer 3
Rationale 1.Acyclovir interferes with DNA synthesis, causing decreased viral replication, and is used to treat herpes.
Rationale 2. Colistin sulfate is effective against most gram-negative entenc pathogens such as Esctierichia coil.
Rationale 3. Cettriaxone (Rocephin) inhibits the synthesis of bacterial cell walls. It is effective against Neisseria gonorrhoeae, a
gram-negative diplococcus. Rationale 4. Dactinomycin is an antineoplastic agent.
55. The nurse is counseling a client who has gonorrhea The nurse should teach this
client that gonorrhea is highly infectious and:
A. Is easily cured
B. Occurs very rarely
C. Can produce sterility
D. Is limited to the external genitalia
Answer C
Rationale A. Many gonococci have become penicillin resistant and difficult to treat.
Rationale B. Gonorrhea is a common sexually transmitted disease.
Rationale C. Inflammation associated with gonorrhea may lead to destruction of the epididymis in males and tubal mucosal
destruction in females, causing sterility.
Rationale D. Neisseria gonorrhoeae will invade internal structures, particularly the epididymis in males and the fallopian tubes
in females.
56. A client is diagnosed with herpes genitalis. What should the nurse do to prevent cross-contamination?
1. Institute droplet precautions.
2. Arrange transfer to a private room.
3. Wear a gown and gloves when giving direct care.
4. Close the door and wear a mask when in the room.
Answer C
Rationale A. The organism is not in respiratory tract secretions: the organism is present in the exudate from active lesions.
Rationale B. This is unnecessary.
Rationale C. The exudate from herpes viws type 2 is highly contagious: gown. gloves, And a facial shield provide a barrier.
Rationale D. This is not an airborne infectious disease.
57. A client is suspected of having rabies after being bitten by dog. For which clinical indicator should the nurse assess the
client?
A. Diarrhea
B. Forgetfulness
C. Urinary stasis
D. Pharyngeal spasm
Answer D
Rationale 1. The CNS is affected: diarrhea is not a concern.
Rationale 2. Memory is not affected by this disease.
Rationale 3. Urinary stasis is not the expected problem: catheterization can be employed
Rationale 4. Painful pharyngeal spasms when swallowing or even looking at water are responsible for the use of the term
hydrophobia to refer to rabies.
58. The nurse assists the physician in performing a lumbar puncture. When pressure is placed on the jugular vein during a
lumbar puncture. the spinal fluid pressure is expected to increase. Which sign should the nurse expect the physician to
document?
A. Homans’ sign
B. Romberg’s sign
C. Chvostek’s sign
D. Queckenstedt’s sign
Answer D
Rationale A. Homans’ sign is calf pain possibly elicited by dorsiflexion of the foot if thrombophlebitis is present.
Rabonale B Romberg’s sign is failure to maintain balance when the eyes are closed:
it indicates cerebellar pathology.
Rationale C. Chvostek’s sign is twitching elicited by tapping the angle of the jaw: it occurs if hypocalcemia is present.
Rationale D. If there is no obstruction, pressure on the jugular vein causes increased intracranial pressure (Queckenstedt’s
sign). This, in turn, causes an increase in spinal fluid pressure.

58. Which type of hepatitis is transmitted by the fecal–oral route via contaminated food, water, or direct contact with an
infected person?
a) Hepatitis A.
b) Hepatitis B.
c) Hepatitis C.
d) Hepatitis D

A. The hepatitis A virus is in the stool of infected people up to two (2) weeks before symptoms develop.
B. Hepatitis B virus is spread through contact with infected blood and body fluids.
C. Hepatitis C virus is transmitted through infected blood and body fluids.
D. Hepatitis D virus only causes infection in people who are also infected with hepatitis B or C.
59. Which type of precaution should the nurse implement to protect from being exposed to any of the hepatitis viruses?
a) Airborne precautions.
b) Standard precautions.
c) Droplet precautions.
d) Exposure precautions.

A. Airborne precautions are required for transmission that occurs by dissemination of either airborne droplet nuclei or dust
particles containing the infectious agent.
B. Standard Precautions apply to blood, all body fluids, secretions, and excretions, except sweat, regardless of whether they
contain visible blood.
C. Droplet transmission involves contact of the conjunctivae of the eyes or mucous membranes of the nose or mouth with
large-particle droplets generated during coughing, sneezing, talking, or suctioning.
D. There is no such precaution known as exposure precautions.
60. The school nurse is discussing ways to prevent an outbreak of hepatitis A with a group of high school teachers. Which
action is the most important intervention that the school nurse must explain to the school teachers?
a) Allow students to eat or drink after each other.
b) Drink bottled water as much as possible.
c) Encourage protected sexual activity.
d) Thoroughly wash hands.

A. Eating after each other should be discouraged, but it is not the most important intervention.
B. Only bottled water should be consumed in Third World countries, but that precaution is not necessary in American high
schools.
C. Hepatitis B and C, not hepatitis A, are transmitted by sexual activity.
D. Hepatitis A is transmitted via the fecal–oral route. Good hand washing helps to prevent its spread.
61. Which instruction should the nurse discuss with the client who is in the icteric phase of hepatitis C?
a) Decrease alcohol intake.
b) Encourage rest periods.
c) Eat a large evening meal.
d) Drink diet drinks and juices.

A. The client must avoid alcohol altogether, not decrease intake, to prevent further liver damage and promote healing.
B. Adequate rest is needed for maintaining optimal immune function.
C. Clients are more often anorexic and nauseated in the afternoon and evening; therefore the main meal should be in the
morning.
D. Diet drinks and juices provide few calories, and the client needs an increased caloric diet for healing.
62. The nurse writes the client problem “imbalanced nutrition: less than body requirements” for the client diagnosed with
hepatitis. Which intervention should the nurse include in the plan of care?
a) Provide a high-calorie intake diet.
b) Discuss total parenteral nutrition (TPN).
c) Instruct the client to decrease salt intake.
d) Encourage the client to increase water intake.
A. Sufficient energy is required for healing. Adequate carbohydrate intake can spare protein. The client should eat
approximately 16 carbohydrate kilocalories for each kilogram of ideal body weight daily.
B. TPN is not routinely prescribed for the client with hepatitis; the client would have to havelost a large of amount of weight
and be unable to eat anything for TPN to be ordered.
C. Salt intake does not affect the healing of the liver.
D. Water intake does not affect healing of the liver, and the client should not drink so much water as to decrease caloric food
intake.
63. The female nurse sticks herself with a dirty needle. Which action should the nurse implement first?
a) Notify the infection control nurse.
b) Cleanse the area with soap and water.
c) Request post-exposure prophylaxis.
d) Check the hepatitis status of the client.Gas
A. The nurse must notify the infection control nurse as soon as possible so that treatment can start if needed, but this is not
the first intervention.
B. The nurse should first clean the needle stick with soap and water to help remove any virus that is on the skin.
C. Post-exposure prophylaxis may be needed, but this is not the first action.
D. The infection control nurse will check the status of the client that the needle was used on before the nurse stuck herself.
64. The client diagnosed with liver problems asks the nurse, “Why are my stools clay colored?” On which scientific rationale
should the nurse base the response?
a) There is an increase in serum ammonia level.
b) The liver is unable to excrete bilirubin.
c) The liver is unable to metabolize fatty foods.
d) A damaged liver cannot detoxify vitamins.

A. The serum ammonia level is increased in liver failure, but it is not the cause of clay-colored stools.
B. Bilirubin, the byproduct of red blood cell destruction, is metabolized in the liver and excreted via the feces, which is what
gives the feces the dark color. If the liver is damaged, the bilirubin is excreted via the urine and skin.
C. The liver excretes bile into the gallbladder and the body uses the bile to digest fat, but it does not affect the feces.
D. Vitamin deficiency, resulting from the liver’s inability to detoxify vitamins, may cause steatorrhea, but it does not cause
clay-colored stool.
65. Which statement by the client diagnosed with hepatitis would warrant immediate intervention by the clinic nurse?
a) “I will not drink any type of beer or mixed drink.”
b) “I will get adequate rest so that I don’t get exhausted.”
c) “I had a big hearty breakfast this morning.”
d) “I took some cough syrup for this nasty head cold.”
A. The client should avoid alcohol to prevent further liver damage and promote healing.
B. Rest is needed for healing of the liver and to promote optimum immune function.
C. Clients with hepatitis need increased caloric intake, so this is a good statement.
D. The client needs to understand that some types of cough syrup have alcohol and all alcohol must be avoided to prevent
further injury to the liver; therefore this statement requires intervention.
66. A client with acquired immunodeficiency syndrome is suspected of having cutaneous Kaposi’s sarcoma. The nurse
prepares the client for which of the following tests to confirm the presence of this type of sarcoma?
A. Sputum culture
B. Liver biopsy
C. Punch biopsy of the cutaneous lesions
D. White blood cell count
Correct Answer: C
Rationale:
Kaposi’s sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large
plaques ulcerate or open and drain. The lesions spread by metastasis to the upper body, then to the face and oral mucosa.
The lymphatic system, lungs, and gastrointestinal (GI) tract can become involved as well. Late disease results in swelling and
pain in the lower extremities, penis, scrotum, or face. Diagnosis is by punch biopsy of cutaneous lesions and biopsy of
pulmonary and GI lesions. Options 1, 2, and 4 are incorrect and would not confirm the presence of
Kaposi’s sarcoma.
67. The nurse is performing an assessment on a female client who complains of fatigue, weakness, muscle and joint pain,
anorexia, and photosensitivity. Systematic lupus erythematosus (SLE) is suspected. The nurse further assesses for which of the
following that also is indicative of SLE?
A. Two hemoglobin S genes
B. Ascites
C. Emboli
D. Butterfly rash on the cheeks and bridge of the nose
Correct Answer: D
Rationale:
SLE is a chronic inflammatory disease that affects multiple body systems. A butterfly rash on the cheeks and bridge of the nose
is a key sign of SLE. Option 1 is found in sickle cell anemia. Options 2 and 3 are found in many conditions but are not
associated with SLE.
68. A child is diagnosed with dengue fever. The etiologic agent for Dengue Hemorrhagic Fever (DHF) is:
a. Chikungunya virus
b. Aedes Aegypti
c. Common household mosquito
d. Infected person
The etiologic agents for DHF are the following:Dengue viruses (1,2,3,4) and Chikungunya virus. Vectors/ source of infection:
Aedes Aegypti, Common household mosquito, Infected person.
69.  Rumpel Leads Test for DHF is positive when:
a. 10-15 petechiae per 2.5 cm square or 1 inch square are observed
b. No petechiae are present
c. 15-20 petechiae per 2.5 cm square or 1 inch square are observed
d. 20 or more petechiae per 2.5 cm square or 1 inch square are observed
Rumpel Leads Test or Torniquet Test is positive when there are 20 or more petechiae per 2.5 cm square or 1 inch square are
observed.
70. Preventive measures for malaria least likely include:
a. Planting of Neem trees and other herbal plants.
b. Wearing of clothing that covers the arms and legs at daytime.
c. Using mosquito repellents, mosquito coils.
d. None of these
Wearing clothing that covers the legs and arms in the EVENING prevents the occurrence of malaria. The vector’s peak biting is
from 9pm to 3am.
71. This parasitic disease that has similar manifestations as pulmonary tuberculosis is:
a. Capillariasis
b. Filariasis
c. Ascariasis
d. Paragonimiasis
The Department of Health (DOH) just recently uncovered a parasitic disease affecting lungs of people who are fond of eating
raw or insufficiently cooked crabs or crustaceans in many parts of the country called Paragonimiasis, it has similar
manifestations as pulmonary tuberculosis that frequently it is misdiagnosed as such.
72. Mrs. Cruz informed the nurse in-charge that her 12 year old girl has been afflicted with cerebrospinal fever 2 years ago.
The nurse understand that the mother is referring to what condition:
a. Meningococcemia
b. Encephalitis
c. Epilepsy
d. Hepatitis
Meningococcemia is also called meningococcal meningitis or cerebrospinal fever.
73. Diagnosis of leprosy is highly dependent on recognition of symptoms. Which of the following is an early sign of leprosy?
A. Macular lesions
B. Inability to close eyelids
C. Thickened painful nerves
D. Sinking of the nosebridge
Answer: (C) Thickened painful nerves The lesion of leprosy is not macular. It is characterized by a change in skin color (either
reddish or whitish) and loss of sensation, sweating and hair growth over the lesion. Inability to close the eyelids
(lagophthalmos) and sinking of the nosebridge are late symptoms.
74. 36. For prevention of hepatitis A, you decided to conduct health education activities. Which of the following is
IRRELEVANT?
A. Use of sterile syringes and needles
B. Safe food preparation and food handling by vendors
C. Proper disposal of human excreta and personal hygiene
D. Immediate reporting of water pipe leaks and illegal water connections
Answer: (A) Use of sterile syringes and needles Hepatitis A is transmitted through the fecal oral route. Hepatitis B is
transmitted through infected body secretions like blood and semen.
75. A 4-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
D. Dysentery
Answer: (B) Cholera
Passage of profuse watery stools is the major symptom of cholera. Both amebic and bacillary dysentery are characterized by
the presence of blood and/or mucus in the stools. Giardiasis is characterized by fat malabsorption and, therefore, steatorrhea.
76. A nurse hears a client calling out for help, hurries down the hallway to the client’s room, and finds the client lying on the
floor. The nurse performs a thorough assessment, assists the client back to bed, notifies the physician of the incident, and
completes an incident report. Which of the following should the nurse document on the incident report?
A. The client fell out of bed.
B. The client climbed over the side rails.
C. The client was found lying on the floor.
D. The client became restless and tried to get out of bed.
Correct Answer: C
Rationale:
The incident report should contain the client’s name, age, and diagnosis. The report should contain a factual description of the
incident, any injuries experienced by those involved, and the outcome of the situation. Option 3 is the only option that
describes the facts as observed by the nurse. Options 1, 2, and 4 are interpretations of the situation and are not factual
information as observed by the nurse.
77. A registered nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is
understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take
which action first?
A. Call the hospital lawyer.
B. Refuse to float to the ICU.
C. Call the nursing supervisor.
D. Report to the ICU and identify tasks that can be performed safely.
Correct Answer: D
Rationale: Floating is an acceptable legal practice used by hospitals to solve understaffing problems. Legally, a nurse cannot
refuse to float unless a union contract guarantees that nurses can work only in a specified area or the nurse can prove the lack
of knowledge for the performance of assigned tasks. When encountering this situation, the nurse should set priorities and
identify potential areas of harm to the client. The nursing supervisor is called if the nurse is expected to perform tasks that he
or she cannot safely perform. Calling the hospital lawyer is a premature action.
78. A hospitalized client tells the nurse that a living will is being prepared and that the lawyer will be bringing the will to the
hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. The
appropriate response to the client is which of the following?
A. “I will sign as a witness to your signature.”
B. “You will need to find a witness on your own.”
C. “Whoever is available at the time will sign as a witness for you.”
D. “I will call the nursing supervisor to seek assistance regarding your request.”
Correct Answer: D
Rationale:
Living wills are required to be in writing and signed by the client. The client’s signature must be witnessed by specified
individuals or notarized. Laws and guidelines regarding living wills vary from state to state, and it is the responsibility of the
nurse to know the laws. Many states prohibit any employee, including a nurse of a facility where the client is receiving care,
from being a witness. Option 2 is nontherapeutic and not a helpful response. The nurse should seek the assistance of the
nursing supervisor.
79. A nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the client’s
record to correct the error. The nurse corrects the error by:
A. Documenting a late entry into the client’s record
B. Trying to erase the error for space to write in the correct data
C. Using correction fluid to delete the error to write in the correct data
D. Drawing one line through the error, initialing and dating the line, and then documenting the correct information
Correct Answer: 4
Rationale:
If the nurse makes an error in narrative documentation in the client’s record, the nurse should follow agency policies to
correct the error. This includes drawing one line through the error, initialing and dating the line, and then documenting the
correct information. A late entry is used to document additional information not remembered at the initial time of
documentation. Erasing data from the client’s record and the use of whiteout are prohibited.
80. Nursing staff members are sitting in the lounge taking their morning break. A nursing assistant tells the group that she
thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the
secretary probably contracted the disease from her husband, who is supposedly a drug addict. Which legal tort has the
nursing assistant violated?
A. Libel
B. Slander
C. Assault
D. Negligence
Correct Answer: B
Rationale: Defamation is a false communication or a careless disregard for the truth that causes damage to someone’s
reputation, either in writing (libel) or verbally (slander). An assault occurs when a person puts another person in fear of a
harmful or an offensive contact. Negligence involves the actions of professionals that fall below the standard of care for a
specific professional group.
81. A nurse calls the physician regarding a new medication prescription because the dosage prescribed is higher than the
recommended dosage. The nurse is unable to locate the physician, and the medication is due to be administered. Which
action should the nurse implement?
A. Contact the nursing supervisor.
B. Administer the dose prescribed.
C. Hold the medication until the physician can be contacted.
D. Administer the recommended dose until the physician can be located.
Correct Answer: A
Rationale: If the physician writes a prescription that requires clarification, the nurse’s responsibility is to contact the physician.
If there is no resolution regarding the prescription because the physician cannot be located or because the prescription
remains as it was written after talking with the physician, the nurse should contact the nurse manager or nursing supervisor
for further clarification as to what the next step should be. Under no circumstances should the nurse proceed to carry out the
prescription until obtaining clarification.
82. The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action
should immediately be taken next?
A. Remove the intravenous (IV) line.
B. Run a solution of 5% dextrose in water.
C. Run normal saline at a keep-vein-open rate.
D. Obtain a culture of the tip of the catheter device removed from the client.
Correct Answer: C
Rationale: If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses normal saline at a keep-
vein- open rate pending further physician prescriptions. This maintains a patent IV access line and aids in maintaining the
clients intravascular volume. The nurse would not remove the IV line because then there would be no IV access route.
Obtaining a culture of the tip of the catheter device removed from the client is incorrect. First, the catheter should not be
removed. Second, cultures are performed when infection, not transfusion reaction, is suspected. Normal saline is the solution
of choice over solutions containing dextrose because saline does not cause red blood cells to clump.
83. A nurse is giving a report to a nursing assistant who will be caring for a client who has hand restraints (safety devices).
The nurse instructs the nursing assistant to check the skin integrity of the restrained hands:
A. Every 2 hours
B. Every 3 hours
C. Every4 hours
D. Every 30 minutes
Correct Answer: D
Rationale: The nurse should instruct the nursing assistant to check safety devices and skin integrity every 30 minutes. The
neurovascular and circulatory status of the extremity should also be checked every 30 minutes. Additionally, the safety device
should be removed at least every 2 hours to permit muscle exercise and to promote circulation. Agency guidelines regarding
the use of safety devices should always be followed.
84. A client has refused to eat more than a few spoonfuls of breakfast. The physician has prescribed that tube feedings be
initiated if the client fails to eat at least half of a meal because the client has been losing weight for 2 months. The nurse
enters the room, looks at the tray, and states, “If you don’t eat any more than that, I’m going to have to put a tube down
your throat and get a feeding in that way.” The client begins crying and tries to eat more. Based on the nurse’s actions,
the nurse may be accused of a tort known as which of the following?
A. Assault
B. Battery
C. Slander
D. Invasion of privacy
Correct Answer: A
Rationale: Assault occurs when a person puts another person in fear of harmful or offensive contact and the victim fears and
believes that harm will occur as a result of the threat. In this situation, the nurse could be accused of the tort of assault.
Battery is the intentional touching of another’s body without the person’s consent. Slander is verbal communication that is
false and harms the reputation of another. Invasion of privacy is committed when the nurse intrudes into the client’s personal
affairs or violates confidentiality.
85. A nurse manager attends a conference, and the topic of discussion is leadership styles. The nurse is seeking a leadership
style that will best empower staff to achieve excellence. Which leadership style would the nurse select to achieve this goal?
A. Autocratic
B. Situational
C. Democratic
D. Laissez-faire
Correct Answer: C
Rationale: Democratic styles best empower staff toward excellence because this style of leadership allows nurses an
opportunity to grow professionally. The autocratic style is task oriented and directive. Situational leadership uses a style that
depends on the situation and events. Laissez-faire allows staff to work without assistance, direction, or supervision.
86. A nurse is supervising a nursing assistant performing mouth care on an unconscious client. The nurse should intervene
if the nursing assistant is observed doing which of the following?
A. Turning the client’s head to one side
B. Using a gloved finger to open the client’s mouth
C. Placing an emesis basin under the clients mouth
D. Using small volumes of fluid to rinse the mouth
Correct Answer: B
Rationale: The client who is unconscious is at great risk for aspiration. The nursing assistant turns the client’s head to the side
and places an emesis basin underneath the mouth. A bite stick or a padded tongue blade is used to open the mouth, not a
gloved finger, to prevent injury to the caregiver. Small volumes of fluids are used to rinse the mouth.
87. A registered nurse is planning the client assignments for the day. Which of the following is the most appropriate
assignment for the nursing assistant?
A. A client with bladder cancer who will be receiving chemotherapy
B. A client on bedrest who requires range-of-motion (ROM) exercises every 4 hours
C. A new diabetes mellitus client scheduled for discharge
D. A client scheduled to receive a blood transfusion
Correct Answer: B
Rationale: The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs
of the client. In this case the most appropriate assignment for a nursing assistant would be to care for a client on bedrest who
requires ROM exercises. The nursing assistant is trained in this procedure. The client receiving chemotherapy and the client
receiving a blood transfusion require the assessment skills that a licensed nurse can perform. The client with diabetes mellitus
who is being discharged will require a predischarge review of diabetic management instructions and potentially coordination
of necessary home care services.
88. The nursing supervisor sends a recently oriented nursing assistant to help relieve the burden of care on a short-staffed
medical-surgical unit. Appropriate duties to delegate to the nursing assistant include:
A. Obtaining routine vital signs and answering call lights
B. Performing range-of-motion exercises and changing sterile dressings
C. Changing linens on occupied beds and documenting client responses to ambulation
D. Caring for clients with transmission-based precautions and changing normal saline infusions
Answer A
Rationale A. These are universal activities that all nursing assistants (NA5) are taught to perform regardless of the setting:
these activities are within the job description of NAs.
Rationale B. Although NAs may perform range-of-motion exercises, they do not have the credentials or expertise to perform
sterile dressing changes.
Rationale C. Although NA5 may change linens on occupied beds, they cannot document client responses in medical records.
Rationale D. Although NM may care for clients with transmission-based
precautions. they may not change intravenous solutions.
89. When planning care for assigned clients, what care can the registered nurse on a medical-surgical unit safely delegate to a
nursing assistant?
A. Evaluating the effectiveness of acetaminophen and codeine (Tylenol No. 3)
B. Obtaining an apical pulse rate before administration of oral digoxin (Lanoxin)
C. Assisting a client who has patient-controlled analgesia (PCA) to the bathroom
D. Assessing the wound integrity of a client recovering from an abdominal laparotomy
Answer: C
Rationale A. Evaluating human responses to health care interventions requires the expertise of a licensed professional nurse.
Rationale B. This activity requires a professional nursing judgment to determine whether or not the medication should be
administered.
Rationale C. This activity does not require professional nursing judgment and is within the job description of nursing assistants.

Rationale D. Evaluating human responses to health care interventions requires the expertise of a licensed professional nurse.
90. The nurse who collaborates directly with the client to establish and implement a plan of care is the:
A. Primary nurse
B. Nurse clinician
C. Clinical specialist
D. Nurse coordinator
Answer A
Rationale A. The primary nurse provides or oversees all aspects of care, including
assessment, implementation, and evaluation of that care.
Rationale B. A clinician is an expert teacher or practitioner in the clinical area.
Rationale C. A clinical specialist is a title given to a specially prepared nurse for one very specific clinical role. It requires a
masters degree level of education.
Rationale D. The nurse coordinator oversees all the staff and clients on a unit and coordinates care.
91. A nurse educator is presenting information about the Nursing Process to a class of nursing students. The nurse educator
states that the Nursing Process can best be defined as the:
A. Implementation of client care by the nurse
B. Steps the nurse employs to meet client needs
C. Activities a nurse employs to identify a client’s problem
D. Process the nurse uses to determine nursing goals for the client
Answer B
Ratnale A. This is only one step in the nursing process.
Rationale B. The nursing process is a step-by-step process that scientifically provides for a clients nursing needs.
Rationale C. This is only one step in the nursing process.
Rationale D. This is only one step in the nursing process.
92. When being interviewed for a position as a registered professional nurse. the applicant is asked to identify an example of
an intentional tort. Which is an appropriate response?
A. Negligence
B. Malpractice
C. Breach of duty
D. False imprisonment
Answer D
Rationale 1. Negligence is an unintentional tort.
Rationale 2. Malpractice. which is professional negligence, is classified as an unintentional tort.
Rationale 3. Breach of duty is an unintentional tort.
Rationale 4. False imprisonment is a wrong committed by one person against another in a willful, intentional way without just
cause and/or excuse.
93. It is most important that the nurse observe the client who has had extensive, prolonged surgery for the depletion of
which electrolyte?
A. Sodium
B. Calcium
C. Chloride
D. Potassium
Answer D
Rationale A. Although sodium may be depleted by nasogastnc suction, retention by
the kidneys generally balances this loss.
Rationale B. This is not depleted by surgery or urinary excretion.
Rationale C. This is not depleted by surgery or urinary excretion.
Rationale D. Release of adrenocortical steroids (cortisol) by the stress of surgery causes renal retention of sodium and
excretion of potassium.
94. A nurse attends an educational conference on leadership styles. A colleague at the conference who is employed at a large
trauma center states that the leadership style at the trauma center is task oriented and directive. The nurse recognizes that
the leadership style used at the trauma center is:
A. Autocratic
B. Situational
C. Democratic
D. Laissez-faire
Correct Answer: A
Rationale:
The autocratic style of leadership is task oriented and directive. Situational leadership style uses a style depending on the
situation and events. Democratic styles best empower staff toward excellence because this type of leadership allows nurses to
provide input and an opportunity to grow professionally. Laissez-faire allows staff to work without assistance, direction, or
supervision.
95. Immediately after a storm has passed, the rescue team with which the nurse is working is searching for injured people. A
victim lying next to a broken natural gas main is not breathing and is bleeding heavily from a wound on the foot. The nurse’s
first step should be to:
A. Treat the victim for shock
B. Start rescue breathing immediately
C. Apply surface pressure to the foot wound
D. Remove the victim from the immediate vicinity
Answer: D
Rationale A. Preventing further injury and reestablishing breathing are the
priorities.
Rationale B. Breathing is the priority once further injury is avoided.
Rationale C. This would be treated after the victim is moved from danger and patency of the airway is verified.
Rationale D. The first action should be to remove the victim from a source of further iury.
96. An arterial blood gas report indicates the clients pH is 725. Pco2 is 35 mm Hg, and HCO; is 20 mEq/L. Which disturbance
does the nurse identify based on these results?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
Answer A
Rationale A.A low pH and low bicarbonate level are consistent with metabolic acidosis.
Rationale B. The pH indicates acidosis.
Rationale C. The CO2 concentration is within normal limits, which is inconsistent with respiratory acidosis.
Rationale D. The pH indicates acidosis.
97. An intentional tort is committed when the nurse
A. Miscounts the gauze pads during a client’s surgery
B. Divulges private information about the client to the media
C. Causes a bum when applying a warm soak to a clienVs extremity
D. Fails to monitor the client’s blood pressure when administering an antihypertensive
Answer 2
Rationale A. This is an example of professional negligence (malpractice).
Rationale B. This is an invasion of privacy, an intentional tort.
Rationale C. This is an example of professional negligence (malpractice).
Rationale D. This is an example of professional negligence (malpractice).
98. What should the nurse do initially when obtaining consent for surgery?
A. Explain the risks involved in the surgery
B. Inform the client that obtaining the signature is routine for any surgery
C. Determine whether the client’s knowledge level is sufficient to give consent
D. Witness the client’s signature because this is what the nurse’s signature is documenting
Answer C
Rationale A. This explanation is not within nursing’s domain.
Rationale B. Although this is true. it does not determine the client’s ability to give informed consent.
Rationale C. Informed consent means the client must comprehend the surgery. the alternatives, and the consequences.
Rationale D. Although this is true. the nurse should first assess the client’s knowledge of the surgery.
99. A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client
is severely hypotensive and unresponsive. The nurse anticipates that which intravenous (IV) solution will most likely be
prescribed to increase intravascular volume, replace immediate blood loss volume, and increase blood pressure?
A. 5% dextrose in lactated Ringer’s
B. 0.33% sodium chloride (1/3 normal saline)
C. 0.225% sodium chloride (1/4normal saline)
D. 0.45% sodium chloride (1/2 normal saline)
Correct Answer:
Rationale:
The goal of therapy with this client is to expand intravascular volume as quickly as possible. The 5% dextrose in lactated
Ringer’s (hypertonic solution) would increase intravascular volume and immediately replace lost fluid volume until a
transfusion could be administered, resulting in an increase in the client’s blood pressure. The solutions in options 2, 3, and 4
would not be given to this client because they are hypotonic solutions and, instead of increasing intravascular space, the
solutions would move into the cells via osmosis.
100A nurse is providing diet instructions to a client with Ménière’s disease who is being discharged from the hospital after
admission for an acute attack. Which statement, if made by the client, indicates an understanding of the dietary measures
to take to help prevent further attacks?
A. “I need to drink at least 3 L of fluid per day.’
B. “I need to restrict my carbohydrate intake.”
C. “I need to maintain a low-fat and low-cholesterol diet.”
D. “I need to be sure to consume foods that are low in sodium.”
Correct Answer: D
Rationale:
Dietary changes, such as salt and fluid restrictions, that reduce the amount of endolymphatic fluid are sometimes
prescribed for the client with Ménière’s disease. The client should be instructed to consume a low-sodium diet and restrict
fluids as prescribed. Although helpful to treat other disorders, low-fat, low-carbohydrate, and low-cholesterol diets are not
specifically prescribed for the client with Ménière’s disease.