A1 PASSERS TRAINING, RESEARCH, REVIEW and c. Notifies the registered nurse (RN) 11.
the registered nurse (RN) 11. A nurse is preparing to perform a neurovascular check for
DEVELOPMENT COMPANY
MEDICAL SURGICAL NURSING
COMPREHENSIVE EXAM
SET 1
1. A nurse is assisting a physician during the examination of an
infant with hip dysplasia and the physician performs the Ortolani
maneuver. The nurse understands that this maneuver is
performed to:
a. Push the unstable femoral head out of the acetabulum.
b. Reduce the dislocated femoral head back into the
acetabulum.
c. Determine the extent of range of motion.
d. Check for asymmetry on the affected side.
2. A 6-month-old infant is seen in the clinic and is diagnosed with
unilateral hip dysplasia. The nurse reviews the health care record
and understands that which of the following findings is not
associated with this condition?
a. An apparent short femur on the affected side
b. Limited range of motion in the affected hip
c. Adduction of the affected hip when placed supine with
the knees and hips flexed
d. Asymmetry of the gluteal skin folds when the infant is
placed prone and the legs are extended against the
examining table
3. A nurse reinforces instructions to the parents of an infant with
hip dysplasia regarding care of the Pavlik harness. The nurse tells
the parents that the:
a. Harness must be worn 12 hours a day.
b. Harness must be removed for diaper changes and for
feeding.
c. Harness is removed to check the skin and for bathing.
d. Infant should never be moved when out of the harness.
4. A nurse provides information to the mother of a 2-week-old
infant diagnosed with clubfoot at the time of birth. Which
statement by the mother indicates a need for further instruction
regarding this disorder?
a. “I need to bring my child back to the clinic in 1 month for
a new cast.”
b. “Treatment needs to be started as soon as possible.”
c. “I need to come to the clinic every week with my child for
the casting.”
d. “I realize my child will require follow-up care until full
grown.”
5. A nurse is assigned to care for a child following spinal fusion for
the treatment of scoliosis. The child complains of abdominal
discomfort and begins to have episodes of vomiting. On further
data collection, the nurse notes abdominal distention. The nurse
takes which action?
a. Administers an antiemetic
b. Places the child in a side-lying Sims’ position
d. Increases the IV fluids
6. A nurse is providing instructions to the parents of a child with
scoliosis regarding the use of a brace. Which statement by a
parent indicates a need for further instruction?
a. “I will apply lotion under the brace to prevent skin
breakdown.”
b. “I need to avoid applying powder under the brace
because it will cake.”
c. “I need to have my child wear a soft fabric under the
brace.”
d. “I need to encourage my child to perform prescribed
exercises.”
7. The mother of a child with juvenile rheumatoid arthritis (JRA)
calls the nurse because the child is experiencing a painful
exacerbation of the disease. The mother asks the nurse if the
child should perform range-of-motion (ROM) exercises at this
time. The nurse makes which response to the mother?
a. “The ROM exercises must be performed every day.”
b. “Avoid all exercise during painful periods.”
c. “Administer additional pain medication before
performing ROM exercises.”
d. “Have the child perform simple isometric exercises
during this time.”
8. A 4-year-old child sustains a fall at home and is brought to the
emergency room by the mother. Following x-ray, it has been
determined that the child has a fractured arm and a plaster cast is
applied. The nurse provides instructions to the mother regarding
cast care for the child. Which statement by the mother indicates a
need for further instruction?
a. “The cast may feel warm as the cast dries.”
b. “If the cast becomes wet, a blow drier set on the cool
setting may be used to dry the cast.”
c. “A small amount of white shoe polish can touch up a
soiled white cast.”
d. “I can use lotion or powder around the cast edges to
relieve itching.”
9. A nurse is assigned to care for a child with a spica cast. The
nurse avoids which of the following when caring for the child?
a. Checking neurovascular status of the extremities
b. Observing for nonverbal signs of pain
c. Placing the child on a stretcher and bringing the child to
the playroom
d. Using pillows to elevate the head and shoulders
10. A child with a fractured femur is placed in Buck skin traction.
The nurse plans care knowing that this type of traction:
a. Requires frequent pin care
b. Places the child at risk for infection
c. Is a type of skin traction that pulls the hip and leg into
extension
d. Uses skeletal traction and weights to provide a
counterforce
tissue perfusion in the child with an arm cast. Which of the
following is the priority in performing this procedure?
a. Taking the blood pressure
b. Taking the temperature
c. Checking the apical heart rate
d. Checking the peripheral pulse in the affected arm
12. A nurse is checking the capillary refill in a child with a cast
applied to the left arm. The nurse compresses the nail bed of a
finger and it returns to its original color in 2 seconds. Based on
this finding, the nurse would:
a. Notify the registered nurse (RN).
b. Document the findings.
c. Prepare the child for bivalving the cast.
d. Elevate the extremity and recheck the capillary refill
immediately.
13. A nurse is performing a neurovascular check on a child with a
cast applied to the lower leg.
The child complains of tingling in the toes distal to the fracture
site. The nurse would:
a. Ambulate the child with crutches
b. Elevate the extremity
c. Document the findings
d. Notify the registered nurse (RN)
14. A nurse is assigned to care for a child in skeletal traction. The
nurse avoids which of the following when caring for the child?
a. Keeping the weights hanging freely
b. Placing the bed linen on the traction ropes
c. Ensuring that the ropes are in the pulleys
d. Ensuring that the weights are out of the child’s reach
15. The nurse is reinforcing information to the mother of a child
about a synthetic cast that has been applied to the child for the
treatment of a clubfoot. Which of the following information will the
nurse provide to the mother?
a. The cast takes 24 hours to dry.
b. The cast is heavier than a plaster cast.
c. The cast is stronger than a plaster cast.
d. The cast allows for greater mobility than a plaster cast.
16. A nursing student is assisting in caring for a client with a lung
tumor who will be having a pneumonectomy. The nursing
instructor reviews the postoperative plan of care developed by the
student and suggests deleting which of the following from the
plan?
a. Monitoring the closed chest tube drainage system
b. Encouraging coughing and deep breathing
exercises
c. Checking the surgical dressing for drainage
d. Avoiding complete lateral positioning
17. A nurse is monitoring a client with a diagnosis of cancer for
signs and symptoms related to vena cava syndrome. The nurse
understands that which of the following is an early sign of this
oncological emergency?
 a. Periorbital edema along with rehydration with IV normal saline. The serum glucose
b. Confusion level is now 240
c. Mental status changes mg/dl. The nurse who is assisting in caring for the client obtains
d. Disorientation which of the following
18. A nurse caring for a client scheduled for a transsphenoidal items, anticipating a physician’s order?
hypophysectomy assists to develop a plan of care for the client. a. IV infusion containing 5% dextrose
The nurse suggests inclusion of which specific information in the b. NPH insulin and a syringe for subcutaneous injection
preoperative teaching plan? c. An ampule of 50% dextrose
a. Hair will need to be shaved d. Phenytoin (Dilantin) for the prevention of seizures
b. Deep breathing and coughing will be needed after 24. A client with diabetes mellitus is being discharged following
surgery treatment for hyperglycemic hyperosmolar nonketotic syndrome
c. Tooth brushing will not be permitted for at least 2 weeks (HHNS) precipitated by acute illness. The client states to the
following surgery nurse, “I will call the doctor next time I can’t eat for more than a
d. Spinal anesthesia will be used day or so.” The nurse plans care understanding that which of the
19. Following a hypophysectomy, the client complains of being following most accurately reflects this client’s level of knowledge?
very thirsty and having to urinate frequently. The initial nursing a. The client needs immediate education before discharge
action is to: b. The client’s statement is accurate but knowledge should
a. Document the complaints be evaluated further
b. Increase fluid intake c. The client’s statement is inaccurate and the client should
c. Check the urine’s specific gravity be scheduled for outpatient diabetic counseling
d. Check for the presence of glucose in the urine d. The client requires follow-up teaching regarding the
20. A nurse is reviewing the physician’s orders for a client with administration of insulin
hypothyroidism. Which of the following medications, if prescribed 25. A physician has prescribed propylthiouracil (Propylthiouracil)
for the client, would the nurse question and verify? for a client with
a. Docusate sodium (Colace) hyperthyroidism, and the nurse assists in developing a plan of
b. Morphine sulfate care for the client. A
c. Levothyroxine (Synthroid) priority nursing measure to be included in the plan regarding this
d. Atenolol (Tenormin) medication is to
21. A client is brought to the emergency room in an unresponsive monitor the client for:
state, and a diagnosis of hyperglycemic hyperosmolar nonketotic a. Signs and symptoms of hypothyroidism
syndrome (HHNS) is made. The nurse who is assisting to care for b. Signs and symptoms of hyperglycemia
the client obtains which of the following immediately in preparation c. Relief of pain
for the treatment of this syndrome? d. Signs of renal toxicity
a. NPH insulin 26. A nurse is monitoring a client with diabetes insipidus.
b. A nasal cannula Desmopressin (DDAVP) has
c. Intravenous (IV) infusion of sodium bicarbonate been prescribed for the client. Which of the following outcomes
d. IV infusion of normal saline reflects a therapeutic
22. A client with a diagnosis of diabetic ketoacidosis (DKA) is effect of this medication?
being treated in the a. Increased serum osmolality
emergency room. Which of the following findings would the nurse b. Increased blood pressure
expect to note as c. Decreased urine output
confirming this diagnosis? d. Decreased urine osmolality
a. Elevated blood glucose and low plasma bicarbonate 27. A nurse is assisting in preparing a care plan for a client with
levels diabetes mellitus who has hyperglycemia. The nurse suggests
b. Decreased urine output addressing which priority problem in the plan of care?
c. Increased respirations and an increase in arterial pH a. Deficient fluid volume
d. Coma b. Deficient knowledge
23. A client is admitted to the hospital with a diagnosis of diabetic c. Imbalanced nutrition
ketoacidosis (DKA). d. Compromised family coping
The initial serum glucose level was 950 mg/dl. Intravenous (IV) 28. A nurse is assigned to care for a client at home who has a
insulin was started diagnosis of type 1 diabetes mellitus. When the nurse arrives to
care for the client, the client tells the nurse that she has been
vomiting and has diarrhea. Which additional statement by the
client indicates a need for reinforcing teaching?
a. “I need to stop my insulin.”
b. “I need to increase my fluid intake.”
c. “I need to call my physician.”
d. “I need to monitor my blood glucose every 4 to 6 hours.”
29. A nurse is assigned to assist in caring for a client admitted to
the emergency room with diabetic ketoacidosis (DKA). In the
acute phase, the priority nursing action is to prepare to:
a. Administer intravenous (IV) regular insulin
b. Administer IV 5% dextrose
c. Correct the acidosis
d. Apply an ECG monitor
30. A client with type 2 diabetes mellitus has a blood glucose level
over 600 mg/dl and
is complaining of polydipsia, polyuria, weight loss, and weakness.
The nurse reviews the
physician’s documentation and would expect to note which of the
following diagnoses?
a. Diabetic ketoacidosis (DKA)
b. Hypoglycemia
c. Hyperglycemic hyperosmolar nonketotic syndrome
(HHNS)
d. Pheochromocytoma
31. A family of a bedridden client with type 2 diabetes mellitus
calls the clinic nurse to
report the following symptoms: blood glucose level 400 mg/dl (by
fingerstick),
polydipsia, and increased lethargy. In determining the client’s
problem, the most
important question to ask the family is which of the following?
a. “Has there been any change in eating patterns?”
b. “Are there any ketones in the urine?”
c. “Has there been any fever?”
d. “Have you increased the amount of fluids provided?”
31. A nurse is preparing to administer an injection of regular
insulin. The vial of
regular insulin has been refrigerated. Upon inspection of the vial,
the nurse finds that the
medication is frozen. The nurse should:
a. Wait for the insulin to thaw at room temperature
b. Check the temperature settings of the refrigerator
c. Discard the insulin and obtain another vial
d. Rotate the vial between the hands until the medication
becomes liquid
32. A nurse has collected data on a client with diabetes mellitus.
Findings include a
fasting blood glucose level of 100 mg/dl, temperature 101° F,
pulse 78 beats per minute,
respirations 22 breaths per minute, and blood pressure 118/78
mm Hg. Which finding
would be of most concern to the nurse?
 a. Pulse and respirations bacille Calmette-Guérin (BCG) vaccine before moving to the 43. A client with acquired immunodeficiency syndrome (AIDS) has
b. Blood pressure United States from a foreign country. The nurse interprets that: become infected with histoplasmosis. The nurse monitors the
c. Blood glucose a. The client’s Mantoux test will be negative, and will client for which of the following signs and symptoms?
d. Temperature require sputum culture to diagnose a. Weight gain
33. A nurse is collecting data from a client newly diagnosed with b. The client’s Mantoux test will be positive, and will require b. Dyspnea
diabetes mellitus chest x-ray for evaluation c. Hypothermia
regarding the client’s learning readiness. Which client behavior c. The client has no risk of acquiring TB, and needs no d. Headache
indicates to the nurse further workup 44. A client has been taking pyrazinamide (Pyrazinamide) for 1
that the client is not ready to learn? d. The client is at more risk of acquiring TB, and needs month. The client asks the nurse if the therapy is due to be
a. The client complains of fatigue whenever the nurse plans immediate medication therapy terminated soon. The nurse determines that the medication
a teaching session 38. The nurse is collecting data on a client with chronic airflow probably will be continued based on a positive finding on which of
b. The client asks if the spouse can attend the classes also limitation (CAL), and notes that the client has a “barrel chest.” The the following reports?
c. The client asks for written materials about diabetes nurse interprets that this client has which of the following forms of a. Blood culture
before class CAL? b. Sputum culture
d. The client asks appropriate questions about what will be a. Chronic obstructive bronchitis c. Urine culture
taught b. Emphysema d. Wound culture
34. A client with diabetes mellitus visits the health care clinic. The c. Bronchial asthma 45. A client who has just suffered a large flail chest is
client had d. Both bronchial asthma and bronchitis experiencing severe pain and
previously been well controlled with glyburide (DiaBeta), but 39. A client is at risk of developing a pulmonary embolism. The dyspnea. The most appropriate nursing action would be to:
recently the fasting blood nurse monitors for which of the following, which is the most a. Document the findings
glucose level has been 180 to 200 mg/dl. Which of the following commonly reported initial symptom? b. Notify the registered nurse
medications, if added a. Dyspnea noted when deep breaths are taken c. Medicate the client for pain
to the client’s regimen, may be contributing to the hyperglycemia? b. Hot, flushed feeling d. Reposition the client
a. Prednisone (Deltasone) c. Chest pain that occurs suddenly 46. A client with no history of respiratory disease is admitted to
b. Atenolol (Tenormin) d. Sudden chills and fever the hospital with respiratory failure. The nurse reviews the arterial
c. Phenelzine sulfate (Nardil) 40. A nurse is assisting in caring for a client who has just returned blood gas reports for which of the following results, which are
d. Allopurinol (Zyloprim) from the postanesthesia care unit after radical neck dissection. consistent with this disorder?
35. A nurse collects urine specimens for catecholamine testing The nurse monitors the portable wound suction for which of the a. PaO2 58 mm Hg, PaCO2 32 mm Hg
from a client with suspected pheochromocytoma. The results of following types of drainage expected in the immediate b. PaO2 60 mm Hg, PaCO2 45 mm Hg
the catecholamine test are reported as 20 mcg/100 mL of urine. postoperative period? c. PaO2 49 mm Hg, PaCO2 52 mm Hg
The nurse analyzes these results as: a. Serosanguinous d. PaO2 73 mm Hg, PaCO2 62 mm Hg
a. Normal b. Grossly bloody 47. A nurse is assisting in caring for a postoperative
b. Lower than normal, ruling out pheochromocytoma c. Serous pneumonectomy client. The nurse monitors the client for which
c. Higher than normal, indicating pheochromocytoma d. Serous with sputum adverse finding indicating acute pulmonary edema?
d. Insignificant and unrelated to pheochromocytoma 41. A client is admitted to the nursing unit experiencing confusion a. Respiratory rate of 20 breaths per minute
36. A physician orders a 24-hour urine collection for VMA. The and tremors. An initial arterial blood gas report indicates that the b. Pain with deep breathing
nurse instructs the client about the procedure for the collection of PaCO2 level is 72 mm Hg while the PaO2 level is 64 mm Hg. The c. Frothy sputum
the urine. Which statement by the client would indicate a need for nurse interprets that the client is most likely experiencing: d. Increased chest tube drainage
further instruction? a. Carbon monoxide poisoning 48. A nurse is assisting in admitting a client to the emergency
a. 1. “I will start the collection in 2 days. I cannot eat or b. Carbon dioxide narcosis room with suspected carbon monoxide poisoning. The nurse
drink any tea, chocolate, vanilla, or fruit until the test is c. Respiratory alkalosis understands that which of the following manifestations is least
completed.” d. Metabolic acidosis reliable for determining the oxygenation status of this client?
b. 2. “When I start the collection, I will urinate and discard 42. A client is admitted to the hospital with a diagnosis of carbon a. Complaints of a headache
that specimen.” dioxide narcosis. In b. Muscular weakness
c. 3. “I will pour the urine in the collection bottle each time I addition to respiratory failure, the nurse plans to monitor the client c. Palpitations
urinate and refrigerate the urine.” for which of the d. Skin color
d. 4. “I can take medications if I need to before the following complications of this disorder? 49. A nurse is assisting in evaluating the respiratory status of the
collection.” a. Paralytic ileus client with carbon dioxide narcosis, who is being mechanically
37. A nurse in an ambulatory clinic is preparing to administer a b. Hypernatremia ventilated. Upon evaluation of a set of arterial blood gases, the
Mantoux skin test to a client who may have been exposed to an c. Increased intracranial pressure nurse notes that the client’s carbon dioxide level has dropped
individual with tuberculosis (TB). The client reports having had the d. Hyperglycemia significantly. The nurse then monitors the client for which adverse
effect of this rapid change?
 a. Tachypnea
b. Hyponatremia
c. Seizure activity
d. Confusion
50. A nurse reviews the nursing care plan of a client and notes
documentation of a nursing diagnosis of impaired gas exchange
related to decreased ventilation and mucous plugs. The nurse
understands that which of the following items documented in the
client’s health care record most accurately indicates achievement
of the expected outcome for this nursing diagnosis?
a. Client demonstrated effective coughing techniques
b. Arterial blood gases indicate a pH of 7.4, PaO2 of 80 mm
Hg, and PaCO2 of 40 mm Hg
c. Venous oxygen saturation of 95%
d. Respiratory rate of 20 breaths per minute
51. A nurse is caring for a client with pheochromocytoma. As part
of the nursing care plan, the nurse monitors for hypertensive
crisis. In the event that hypertensive crisis occurs, the nurse
would anticipate that the most likely medication to be prescribed
would be:
a. Propranolol (Inderal)
b. Phentolamine mesylate (Regitine)
c. Phenoxybenxamine hydrochloride (Dibenzyline)
d. Prazosin hydrochloride (Minipress)
52. Prednisone (Deltasone) 10 mg orally daily has been
prescribed for the client. The nurse provides instructions to the
client regarding the medication. Which statement by the client
indicates that further teaching is necessary?
a. “I need to take the medication every day at the same
time.”
b. “I can take acetylsalicylic acid (aspirin) or my
antihistamine if I need it.”
c. “If I gain more than 5 pounds a week, I will call my
doctor.”
d. “I need to avoid coffee, tea, cola, and chocolate in my
diet.”
53. A client arrives at the emergency department following a blow
to the eye from a softball. The initial nursing action is to:
a. Perform a thorough eye examination
b. Irrigate the eye with sterile cool water
c. Place the client in the supine position on a stretcher
d. Apply ice to the affected eye
54. A nurse receives a telephone call from a neighbor who tells
the nurse that the spouse accidentally broke a mirror and a piece
of glass flew into the eye. The nurse arrives at the home and finds
that a piece of glass is protruding from the victim’s eye. The
appropriate nursing action is to:
a. Remove the piece of glass using tweezers that were
boiled for sterilization purposes
b. Apply an eye patch and instruct the victim and spouse to
report to the emergency department
c. Accompany the victim and spouse to the emergency
department
d. Flush the eye thoroughly with tap water
55. A client arrives at the emergency department following an eye
injury in which acid, used to clean a brick on the fireplace,
splashed into the eye. The initial question by the nurse is which of
the following?
a. “Did you bring the container of acid with you?”
b. “What time did the injury occur?”
c. “Did you flush the eye following the injury?”
d. “What type of acid caused the injury?”
56. A nurse has been hired by the health care clinic to assist in
conducting hearing tests in a local neighborhood. The nurse in
charge of the clinic is observing the nurse perform a voice test to
assess hearing in a client. Which of the following observations
indicates that the nurse is performing the procedure correctly?
a. Stands 10 feet away from the client to determine if the
client can hear clearly
b. Asks the client to block one ear, whispers a statement,
and asks the client to repeat it
c. Whispers a statement with the back facing the client
d. Asks the client to block both ears, faces the client,
verbalizes a statement, and asks the client to repeat the
statement
57. A nursing student is caring for a client with a diagnosis of
presbycusis. During the clinical conference, the nursing instructor
asks the student to describe this disorder to the other students.
Which statement by the student indicates an understanding of this
disorder?
a. “It is a sensorineural hearing loss that occurs with aging.”
b. “It is a conductive type of hearing loss that occurs in
middle age.”
c. “It is a common type of hearing loss that occurs from
exposure to loud noise.”
d. “It is caused by aging and causes tinnitus and
nystagmus.”
58. A nurse instructs a client with Meniere’s disease regarding the
prescribed dietary measures to treat the disorder. The nurse
determines that the client understands the instructions if the client
states that which food will be avoided in the diet?
a. Cereal products
b. Hot dogs
c. Citrus foods
d. Green, leafy vegetables
59. A nurse is assisting in developing a plan of care for a client
following a craniotomy for removal of an acoustic neuroma. The
nurse suggests including in the plan of care measures that will
identify complications specifically associated with this type of
surgical procedure. Which of the following will be included in the
plan of care?
a. Assessment of taste sensations
b. Assessment of ability to tolerate range-of-motion
exercises
c. Assessment of ability to smell
d. Assessment of cranial nerve VII (facial nerve)
60. A client is being discharged from the ambulatory care unit
following cataract removal and the nurse reinforces instructions
regarding home care. Which of the following instructions will the
nurse include in the teaching plan?
a. Take acetaminophen (Tylenol) if any discomfort occurs
b. Sleep on the side that was operated on to promote
drainage
c. Avoid wearing glasses
d. Do not lift anything that weighs more than 10 lb
61. A nurse is reinforcing instructions to a client following a
cataract extraction. Which statement by the client indicates a
need for further teaching?
a. “I need to avoid bending over to pick up items.”
b. “I will sleep on the nonoperative side.”
c. “I need to wear an eye shield all the time.”
d. “There is no reason to stay on a special diet.”
62. A nurse is performing eye testing on a client and is using a
Snellen chart. The nurse documents the test results as 20/80
vision, and the client asks the nurse to describe what these
numbers mean. The appropriate response by the nurse is which
of the following?
a. “You can read at a distance of 80 feet what a
client with normal vision can read at 20 feet.”
b. “Your vision is improving.”
c. “Your vision is normal.”
d. “You can read at a distance of 20 feet what a
client with normal vision can read at 80 feet.”
63. A nurse is reviewing the record of a client admitted to the
hospital for treatment of bladder cancer. Which of the following
risk factors related to this type of cancer will the nurse most likely
note in the client’s record?
a. Female African American
b. Recorded age of 35 years
c. Occupation of computer analyzer
d. Drinks a pot of coffee every day
64. A nurse is collecting data from a client admitted to the hospital
with a diagnosis of bladder cancer. Which question should the
nurse ask the client to determine if the client is experiencing the
most common symptom associated with this type of cancer?
a. “Do you have frequency with urination?”
b. “Do you commonly feel the urge to urinate?”
c. “Do you experience any pain when you urinate?”
d. “Do you notice any blood in the urine?”
65. A nurse is assisting in preparing a client for an intravesical
instillation of an alkylating chemotherapeutic agent into the
bladder for the treatment of bladder cancer. The nurse reinforces
instructions to the client regarding the procedure. Which
statement by the client indicates an understanding of this
procedure?
a. “I will need to immediately urinate after the instillation is
done.”
b. “I need to stay on bed rest after the procedure is
completed.”
c. “After the instillation is done, I will need to retain the fluid
for 30 minutes.”
d. “After the instillation is done, I will need to change
positions every 15 minutes from side to side.”
66. A nurse is inspecting the stoma of a client following an
ureterostomy and notes that the stoma appears pale. Which
interpretation does the nurse make based on this finding?
a. An inadequate amount of vascular supply to the stoma
b. A normal appearance of the stoma
c. A fluid volume deficit
d. A fluid volume excess
67. A nurse has provided instructions to a client scheduled for a
mammography regarding the procedure. Which statement by the
client indicates an understanding of the procedure?
a. “The test takes about 1 hour and is painless.”
b. “I cannot wear deodorant on the day of the test.”
c. “I will need to wear a sports bra for the procedure.”
d. “I cannot eat on the day of the test.”
68. A nurse informs the client that a Papanicolaou smear will be
done at the next scheduled clinic visit, and the nurse provides
instructions to the client regarding preparation for this test. Which
statement by the client indicates an understanding of the
procedure?
a. “If I have my period at the time of my next scheduled
visit, I will not be able to have
the test done.”
b. “I need to restrict fluids on the day of the test.”
c. “The test is painful and will cause cramping.”
d. “I need to do a vaginal douching with vinegar and water
on the morning of my
appointment.”
69. A nurse is caring for a client with metastatic lung cancer. The
client was medicated 2 hours ago and now complains of a new
and sudden sharp pain in the back. The nurse appropriately
interprets this finding as possibly indicating:
a. The need for an increase in pain medication
b. A low pain threshold
c. Further metastasis
d. Spinal cord compression
70. A client who had abdominal surgery has an episode of
vomiting. During the episode of
vomiting, the client states, “I feel as if I just split open.” The nurse
removes the abdominal dressing, assesses the surgical site, and
determines that which of the following occurred if this wound
appearance was observed?
a. Dehiscence
b. Evisceration
c. Infection
d. Partial separation of outer wound layers
71. A client arrives in the emergency department with a bloody
nose. The initial nursing action is to:
a. Place the client in a supine position
b. Apply an ice collar around the client’s neck
c. Assist the client to a sitting position with the head tilted
forward
d. Instruct the client to swallow the blood until the bleeding
can be controlled
72. A nurse is assisting in providing a session to community
members about the risks associated with laryngeal cancer. Which
statement by a client indicates an understanding of the risk
factors?
a. “Cigarette smoking does not contribute to the
development of this type of cancer.”
b. “Alcohol consumption is not associated with this form of
cancer.”
c. “Exposure to airborne carcinogens can cause this type of
cancer.”
d. “Persistent use of the voice is not associated with this
type of cancer unless spitting up of blood occurs.”
73. Kanamycin sulfate (Kantrex) by intermittent intravenous
infusion is prescribed for a client with a respiratory tract infection.
A nurse assigned to care for the client is instructed to monitor for
adverse reactions related to the medication. Which of the
following indicates to the nurse that the client is experiencing an
adverse reaction?
a. Gastrointestinal disturbances
b. Difficulty hearing
c. An elevated white blood cell count
d. A decreased blood urea nitrogen (BUN)
74. A nurse is providing information to a client scheduled for a
lumbar puncture. Which of the following information will the nurse
provide to the client?
a. Food and fluids will be restricted until after the test
b. There is no need to maintain bed rest following the test
c. An informed consent will be required
d. The test will probably take about 2 hours
75. A nurse is assisting the physician in performing a lumbar
puncture on a client. The nurse prepares the client for the
procedure by placing the client in which of the following positions?
a. Supine
b. Prone
c. Lateral
d. Fetal
76. A nurse is preparing to care for a client following a lumbar
puncture. The nurse plans to place the client in which of the
following positions immediately after the procedure?
a. Supine with a pillow under the head
b. Prone with a pillow under the abdomen
c. Prone in semi-Fowler’s position
d. Lateral with the head slightly higher than the rest of the
body
77. A nurse is monitoring a client who has returned to the nursing
unit following a myelogram. Which of the following client
complaints indicates the need to notify the registered nurse?
a. Headache
b. Neck stiffness
c. Feelings of fatigue
d. Backache
78. A nurse is providing instructions to a client scheduled for
magnetic resonance imaging (MRI). Which of the following
instructions does the nurse provide to the client?
a. The test will require that a dye be injected
b. Fluids and food are restricted for 12 hours before the test
c. Earplugs can be worn if the noise from the machine is
uncomfortable
d. The test may cause some pain but pain medication will
be prescribed if pain occurs
79. A client with cancer is receiving morphine sulfate10 mg
subcutaneously every 3 to 4 hours for pain. When writing the plan
of care for this client, the nurse should include as a priority action
to:
a. Monitor the client’s temperature
b. Monitor the urine output
c. Encourage the client to cough and deep breathe
d. Encourage increased fluids
80. A nurse has administered a dose of meperidine hydrochloride
(Demerol) 100 mg to a client with renal colic as treatment for pain.
The nurse carefully monitors this client for which side effect of this
medication?
a. Hypertension
b. Increased respirations
c. Urinary retention
d. Bradycardia
81. A nurse has given instructions for taking codeine sulfate to a
client with a severe headache. The nurse interprets that the client
understands the information presented if the client states to do
which of the following while taking this medication?
a. Avoid all exercise to prevent light-headedness
b. Avoid the use of stool softeners to prevent diarrhea
c. Increase fluid intake
d. Maintain a low-fiber diet
82. A client experiencing spasticity resulting from a spinal cord
injury has a new order for dantrolene sodium (Dantrium). Before
administering the first dose, the nurse checks to see if which of
the following baseline studies has been done?
a. Liver function studies
b. Otoscopic examination
c. Blood glucose measurements
d. Renal function studies
83. A client with gout has begun taking allopurinol (Zyloprim). The
nurse provides
which instruction to the client for use of the medication?
a. Take the medication 1 hour before eating
b. Put ice on the upper and lower lips if they swell
c. Use an antihistamine lotion if an itchy rash develops
d. Drink at least eight glasses of fluid every day
84. Auranofin (Ridaura) has been prescribed for a client with
rheumatoid arthritis. The nurse who is collecting data from the
client 2 weeks later in the clinic interprets that which of the
following client complaints is unrelated to an early sign of
medication toxicity?
a. Constipation
b. Mouth lesions
c. Pruritus
d. Metallic taste in the mouth
85. An older client with rheumatoid arthritis has been instructed by
the physician to take ibuprofen (Motrin) 300 mg orally four times
daily. The nurse reading the medication order interprets that the
prescribed dosage is:
a. Higher than the normal adult dosage
b. An unusual dosage for this diagnosis
c. The normal adult dosage
d. Lower than the normal adult dosage
86. A nurse is asked to assist another health care member in
providing care to a client. On entering the client’s room, the nurse
notes that the client is placed in modified tredelenburg position .
The nurse interprets that the client is most likely being treated for:
a. A head injury
b. Respiratory insufficiency
c. Shock
d. Increased intracranial pressure
87. An emergency department nurse has administered 5 mL of
syrup of ipecac to a 10-month-old child, followed by half a glass of
water. The nurse evaluates that themedication had an effective
response if which of the following is noted?
a. Increased level of consciousness
b. Elevated blood pressure
c. Vomiting
d. Diarrhea
88. A nurse is assisting in monitoring a client with acute
lymphocytic leukemia for toxic effects of asparaginase (Elspar).
The nurse should notify the registered nurse if which of the
following is noted?
a. Oral ulcerations
b. Alopecia
c. Prolonged blood clotting times
d. Decreased white blood cell count
89. A client taking metronidazole (Flagyl) telephones the clinic
nurse to complain about dark discoloration of the urine. The nurse
interprets that the client’s complaint warrants which of the
following nursing actions at this time?
a. Tell the client that this is a harmless medication side
effect
b. Instruct the client to increase fluid intake
c. Instruct the client to call the physician
d. Tell the client to discontinue the medication
90. A client with acquired immunodeficiency syndrome (AIDS)
who is taking zidovudine (Retrovir) has severe neutropenia noted
on follow-up laboratory studies. The nurse interprets that which of
the following is likely to occur at this point?
a. Prednisone (Deltasone) will probably be added to the
medication regimen
b. Epoetin alfa (Epogen) will probably be added to the
medication regimen
c. The medication dose will probably be reduced
d. The medication will probably be discontinued until
laboratory results indicate bone marrow recovery
91. A client with acquired immunodeficiency syndrome (AIDS)
experiences nausea, vomiting, and abdominal pain after taking
didanosine (Videx). The clinic nurse provides which of the
following as telephone advice to this client?
a. Take crackers and milk with each dose of the medication
b. Decrease the dose of the medication until the next clinic
visit
c. This is an uncomfortable but expected side effect of the
medication
d. Come to the health care clinic to be seen by the
physician
92. Psyllium (Metamucil) is prescribed for a client with a cardiac
disorder to facilitate defecation and prevent straining with bowel
movements. The nurse provides instructions to the client
regarding administration of the medication. Which statement by
the client indicates an understanding of the use of the
medication?
a. “I need to mix the medication with custard.”
b. “I should decrease the amount of fiber in my diet when I
take this medication.”
c. “I should mix the medication with a full glass of water.”
d. “I need to decrease my fluid intake following
administration of the medication.”
93. A nurse is reviewing the laboratory results of a client receiving
chemotherapy. The nurse prepares to initiate neutropenic
precautions when the nurse notes which of the following
laboratory results?
a. A white blood cell (WBC) count of 2000/μL
b. A platelet count of 100,000 cells/μL
c. A clotting time of 10 minutes
d. An ammonia level of 20 mcg/dl
94. Cyclophosphamide (Cytoxan) is prescribed for a client with a
diagnosis of breast cancer. The nurse has provided instructions to
the client regarding the medication. Which statement by the client
indicates an understanding of this chemotherapeutic regimen?
a. “I need to take the medication with food.”
b. “I need to avoid salt while taking this medication.”
c. “I need to eat a banana and drink a glass of orange juice
every day.”
d. “I need to increase my fluid intake to 2000 to 3000 mL
daily.”
95. A nurse reinforces discharge instructions to a postoperative
client taking warfarin sodium
(Coumadin). Which statement by the client indicates the need for
further teaching?
a. “I will take Ecotrin for my headaches because it is
coated.”
b. “I will be certain to limit my alcohol consumption.”
c. “I will take my pills every day at the same time.”
d. “I have already called my family to pick up a Medic Alert
bracelet.”
96. A nurse is assigned to care for a client who has returned to
the nursing unit following a left nephrectomy. The nurse places
the highest priority on monitoring which of the following?
a. Tolerance for sips of clear liquids
b. Oxygen saturation levels
c. Hourly urine output
d. Ability to turn side to side
97. A nurse is caring for a client experiencing thyroid storm.
Which of the following would be a priority nursing diagnosis for
this client?
a. Risk for decreased cardiac output
b. Disturbed body image
c. High Risk for sexual dysfunction
d. Ineffective coping
98. A nurse is collecting data on a client with hyperparathyroidism.
Which of the following questions would elicit the most accurate
information about this condition from the client?
a. “Have you had problems with diarrhea lately?”
b. “Do you have tremors in your hands?”
c. “Are you experiencing pain in your joints?”
d. “Do you notice swelling in your legs at night?”
99. fingers of both hands become cold, pale, and numb. The client
states that they then become reddened and swollen with a
throbbing, achy pain. The nurse further collects data on the client
to see if these episodes occur with:
a. Exposure to heat
b. Being in a relaxed environment
c. Prolonged episodes of inactivity
d. Ingestion of coffee or chocolate
100. A client is admitted to the hospital with pericarditis. The
nurse reviews the client’s record for which manifestation that
differentiates pericarditis from other cardiopulmonary problems?
a. Chest pain that worsens on expiration
b. Pericardial friction rub
c. Anterior chest pain
d. Weakness and irritability