PREDICTOR EXAM – Nursing Practice 1
    The nurse is teaching a client with
1)     The nurse is having difficulty reading a
physician’s order for a medication. The
nurse knows the physician is very busy and
does not like to be called. The nurse
should:
a) Call the charge nurse to verify the order
b) Page for the supervisor on duty to verify her
about the ordered medication
c) Give the medication, the patient needs it and
just document in the chart that the doctor is so
busy and he does not want to be called and
that you are going to call him later
d) Call the physician to have the order clarified
2)     The nurse is preparing to administer
medications to two clients with the same
last name. The nurse checks the medication
three times before entering the room to
administer medications to the first client.
While leaving the room of the following
administration, the nurse realizes she did
not check the identification of the client
prior to administering medication. Which of
the following actions should the nurse
complete first?
a) Return to the room to check the client
identification and complete a variance report if
an error was made.
b) Administer the remaining medication to eh
other client and check the client identification.
c) Alert the charge nurse that a medication
error has been committed.
d) Document completion of the variance report
and the medication error in the client’s chart
and notify the physician.
3)     The nurse is assessing a client with
chronic bronchospasm, which is treated
with oral theophylline. Which of the
following serum theophylline levels
requires immediate nursing action?
a) 8 μg/mL.
b) 20 μg/mL.
c) 12 μg/mL.
d) 25 μg/mL.
4) 
asthma about the proper use of a metered-
dose inhaler. Which statement by the client
indicates that the teaching was effective?
a) “I’ll flex my head forward and breathe out
forcefully before inhaling the drug.”
b) “As I press down on the canister, I’ll inhale
slowly over 10 seconds.”
c) “I’ll hold my breath for 5 second after
inhaling the drug to allow the drug to reach my
lungs.”
d) “I’ll wait one minute between puffs.”
5)     A nurse is having difficulty setting up
humidified oxygen at 40% per Venturi mask
and does not know how many liters of flow
she should use. Which if the following
actions is most appropriate to ensure safe
oxygen administration?
a) Consult with a respiratory therapist.
b) Look at the package directions and try to
figure it out.
c) Ask the nursing assistant how to set it up.
d) Use a regular oxygen mask.
6)     Five minutes after receiving a
preoperative sedative medication by IV
injection, a patient asks the nurse to get up
to go to the bathroom to urinate. Which of
the following is the most appropriate action
for the nurse to take?
a) Assist patient to bathroom and stay next to
door to assist patient back to bed when done.
b) Allow patient to go to the bathroom since the
onset of the medication will be more than 5
minutes.
c) Offer the patient to use the urinal/bedpan
after explaining the need to maintain safety.
d) Ask patient to hold the urine for a short
period of time since a urinary catheter will be
placed in the operating room.
7)     The prime issue after administration of
either sedative or opioid analgesic
medications is safety. Because the
medications affect the central nervous
system, the patient is at risk for falls and
should nto be allowed out of bed, even with
assistance. Before admitting a patient to the
operating room, the nurse recognizes that
which of the following must be attached to
the chart of all patients?
a) A functional status evaluation
b) Observing the operative tests
c) A physical examination report
d) An electrocardiogram
8)     Which of the following nursing
interventions should receive highest
priority when a patient is admitted to the
postanesthesia care unit?
a) Positioning the patient
b) Observing the operative site
c) Checking the postoperative orders
d) Receiving report from operating room
personnel
9)     During which phase of the nursing
process does data get collected and
validated with the patient and/or family
members by the nurse?
a) The implementation phase
b) The assessment phase
c) The evaluation phase
d) The planning phase
10)     Which of the following is the best
worded expected outcome?
a) “The nurse will provide for adequate
hydration”
b) “The nurse will ensure that the patient is
safe”
c) “The patient will cough and deep breathe
every two hours”
d) “The patient will value health”
11)     What is the major difference between
a problem oriented medical record and a
source oriented medical record?
a) The problem oriented medical system has a
centralized part of the chart for interdisciplinary
progress notes and the source oriented
medical record has separate areas for each
profession’s progress notes.
b) The problem oriented medical system
consists of narrative progress notes and the
source oriented medical record uses SOAP.
c) The source oriented medical system uses
charting by exception and the source oriented
medical record system does not.
d) The source oriented medical system has a
centralized part of the chart for interdisciplinary
progress notes and the problem oriented
medical record has separate areas for each
profession’s progress notes.
12)     Which of the following healthcare
providers can legally have access to all, or
part, of a patient’s medical record because
they have a “need to know”? 
1.     Student nurses caring for a particular
patient
2. Registered nurses when they are not caring
for a particular patient
3.     The Vice President for Nursing who is
investigating a patient fall
4.     Licensed practical nurses caring for a
particular patient
5.     A quality assurance nurse collecting data
for a performance improvement activity
a) 1, 2, 3 and 4 only
b) 1, 2, 4 and 5 only
c) 1, 3, 4 and 5 only
d) All of the above
13)     The staff nurse delegates AM care for
two patients to the CAN. What principle of
delegation is the nurse following?
a) Delegation requires a situation with clearly
defined superiors.
b) You can delegate only those tasks for which
you are responsible.
c) Delegation can only exist with a subordinate.
d) Delegation is a tool only used by nurses.
14)     Which of the following is an important
principle of delegation?
a) Responsibility is not transferred with
delegation
b) Delegation is the same as work allocation
c) No transfer of authority exists when
delegating
d) When delegating, you must transfer
authority a. All of the above
b. 1,2 3 and 6 only
15)     The staff nurse in a long-term care c. 1, 3, 5 and 6 only
facility wants to delegate the passing of 9 d. 1, 2, 4 and 6 only
AM medications. The additional staff
consists of two CNAs. What type of barrier 20)   Which is considered an internal
to delegation exists? disaster?

a) Poor communication a) A patient fall

b) Lack of resources b) The massive spread of pneumonia
c) Approval versus affiliation c) A computer hacking episode
d) Trust versus control d) Unexpected staff absences due to illness

16)     Which quality assurance or 21)     Place these human needs in order
performance improvement technique is from the greatest priority to the least
used to identify underlying process flaws? priority using #1 as the greatest priority and
#5 as the least of all in terms of priority.
a) Small group process 1.    Self-esteem and esteem by
b) People at fault process others               
c) Root cause analysis 2.    Self actualization                    
d) Cause and effect 3.    Psychological needs
4.    Love and belonging   
17)     Select the nursing theorist who is 5.    Physiological need
accurately paired with the theory or model
of nursing that they are credited with. a) 5, 3, 4, 1, 2
b) 5, 4, 1, 3, 2
a) The Twelve Nursing Problems: Faye Glenn b) 5, 4, 3, 1, 2
Abdellah d) 5, 4, 3, 2, 1
b) The Nature of Nursing: Imogene King
c) The Goal Attainment Theory: Virginia 22)     How many minims are contained in 1
Henderson milliliter?
d) The Interpersonal Relations Model:
Hildegard Peplau a) Between 10-11
b) 20
18)     Which legal document will most likely c) 12
contain the patient’s decision to not get d) Between 15 or 16
cardiopulmonary resuscitation?
23)     Your long-term care patient has
a) Healthcare surrogacy chronic pain and at this point in time the
b) Advance directives patient needs increasing dosages to
c) Healthcare proxy adequately control this pain. What is this
d) Durable power of attorney patient most likely to be affected with?

19)     Which of the following are necessary a) Drug addiction

elements of malpractice?  b) Drug side effects
1.     A breach of duty                                 c) Drug interactions
2.     Forseeability d) Drug tolerance
3.     An intentional act                               
4.     Patient harm 24)     Which statement about adjuvant
5.     A nonintentional act                            medications is true and accurate?
6.     Causation
a) Licensed practical nurses cannot administer how they deal with the loss of a client. The
adjuvant medications analysis of the interviews yields common
b) Adjuvant medications are schedule 2 themes describing the nurse’s grief. This is
narcotics an example of a(n):
c) Adjuvant medications are schedule 1
narcotics a) Historical study
d) Adjuvant medications can be purchased b) Correlational Study
over the counter c) Qualitative study
d) Experimental study
25)     Select the ethical principles that are
paired with their description.  29)     An operating room nurse is taking
1.     Justice: being honest with colleagues during a meeting and asks,
2.     Beneficence: Do no harm “I wonder if we would see fewer wound
3.     Veracity: Treating all patients equally infections if we use Chlorhexidine instead
4.     Self determination: Facilitating patient of povidone–iodine to clean the skin of our
choices surgical clients?” In this example of a PICO
5.     Beneficence: Do good questions, the P is:
6.     Justice: equality and equity
a) Betadine use
a) 1, 4, 5 b) Chlorhexidine
b) 2, 4, 6 c) Surgical clients
c) 3, 4 ,5 d) Operating room nurse
d) 4, 5, 6
30)     The foundation of research is based
26)     Which patient is exercising their right on which of the following:
to autonomy in the context of patience
rights? a) Evidence
b) Critical thinking
a) An 86 year old female who remains c) Experience
independent in terms of the activities of daily d) Scientific method
living
b) An unemancipated 16 years old who
chooses to not have an intravenous line.
c) A 32 year old who does not need the help of
the nurse to bathe and groom themselves.
d) A 99 year old who wants CPR despite the
fact that the nurse and doctor do not think that
it would be successful.

27)     A study examines the change in heart

rate that occurs after chest physical therapy
in a patient with pneumonia. Which of the
following is the dependent variable?

a) Pneumonia
b) Chest percussion
c) Heart rate
d) Presence or absence of chest physical
therapy

28)     A nurse researcher interviews senior

oncology nurses, asking them to describe
Nursing Practice 2
31)     Which client would most benefit from
acupressure, a traditional Chinese medicine
which is considered Complementary
Alternative Medicine (CAM)?
a) A client with thyroid cancer who has
chemotherapy induced nausea
b) A client with type 2 diabetes diagnosed with
chronic renal disease
c) The postpartum client who is diagnosed with
Sheehan syndrome
d) The client diagnosed with arterial
hypertension
32)     The client with AIDS tells the nurse
that has been using acupuncture to help
with his pain. The nurse should questions
the client regarding this treatment because
acupuncture:
a) Uses pressure from the fingers and hands to
stimulate the energy points in the body
b) Uses oils extracted from plants and herbs
c) Uses needles to stimulate certain points on
the body to treat pain
d) Uses manipulation of the skeletal muscles to
relieves stress and pain
33)     R.A. 7719 otherwise known as the
Blood Services Act of 1994,” aims to
promote and encourage voluntary blood
donation by the citizenry to instill public
consciousness of the principle that blood
donation is a humanitarian act. To ensure
safety of blood supply, donors must meet
certain requirements before donating. To be
eligible a blood donor must:
a) Weight at least 45 kg. but ideally 50 kg. or
more
b) Age 16-65 (ages 16-17 should present
parental consent)
c) Hemoglobin of at least 14 g/dl
d) Have BP in safe range 90-160 mmHg
systolic; 60-100 mmHg diastolic
34) Who is credited with the stages of
cognitive development?
a) Erikson
b) Piaget
c) Freud
d) Lister
35)     Which of the following is a vector of
infection? 
a) A contaminated ball
b) An infected person
c) A contaminated thermometer
d) An infectious fly
36)     Select the method of special that is
accurately paired with the personal
protective equipment that is minimally
required in order to prevent the spread of
infection.
a) Contact precautions: Gowns, Gloves, and
mask
b) Droplet precautions: face mask
c) Airborne transmission precautions: negative
pressure room
d) Contact precautions: Gloves
37)     Which of these patients is affected
with a healthcare acquired infection?
a) An 18 year old male patient who developed
an intravenous line infection two days after
insertion
b) A 72 year old male patient who is at risk for
infection secondary to AIDS/HIV
c) A 67 year old female patient who was
admitted with a urinary tract infection
d) A 5 year old pediatric patient who develops
the measles rash 3 days after admission
38)     The stages of infection in correct
sequential order are:
a) The prodromal, incubation, illness and
convalescence stages
b) The incubation, prodromal, illness and
convalescence stages
c) The prodromal, primary secondary and
tertiary stages
d) The inflammation, infection and immunity
stages
39)     What is the single most important
thing that nurses do in order to prevent the
spread of infection?
a) Applying standard precautions
b) Using personal protective equipment
c) Adhering to the principles of asepsis
d) Hand washing
40)     Which pain assessment scale is used
exclusively for infants and neonates from
32 weeks of gestation to six months of age?
a) The PEPPS pain scale
b) The Faces pain scale
c) The FLACC pain scale
d) The CRIES pain scale
41)     When a 12-year-old child is
prescribed methylphenidate, which is most
important for the nurse to monitor?
b) The child’s respirations
c) The child’s intake and output
d) The child’s height and weight
42)     A maternity nurse is providing
instruction to a new mother regarding the
psychosocial development of the newborn
infant. Using Erikson’s psychosocial
development theory, the nurse would
instruct the mother to
a) Allow the newborn infant to signal a need
b) Anticipate all of the needs of the newborn
infant
c) Avoid the newborn infant during the first 10
minutes of crying
d) Attend to the newborn infant immediately
when crying
43)     A mother of a 3-year-old tells a clinic
nurse that the child is rebelling constantly
and having temper tantrums. The nurse
most appropriately tells the mother to:
a) Punish the child every time the child say’s
“no”, to change the behavior
b) Allow the behavior because this is normal at
this age period
c) Set limits on the child’s behavior
d) Ignore the child when this behavior occurs
44)     The nurse is teaching a
postmenopausal patient with breast cancer
about the expected outcomes of her cancer
treatment. The nurse evaluates that the
teaching has been effective when the
patients says
a) “After cancer has not recurred for 5 years, it
is considered cured.”
b) “I will need to have follow-up examinations
for many years after I have treatment before I
can be considered cured.”
c) “Cancer is considered cured if the entire
tumor is surgically removed.”
d) “Cancer is never considered cured, but the
tumor can be controlled with surgery,
chemotherapy, and radiation.”
45)     During the breast exam, the nurse
asks the client to raise her arms over her
head. Why did the nurse change the client’s
position?
a) Skin dimpling is accented in this position.
b) The nurse couldn’t palpate the axillae
correctly
c) The client has small breasts
d) The client has large breasts.
46)     The client tells the nurse, “At times I
have drainage from my right breast.” What
should the nurse do with this information?
a) Write it in the medical record and say
nothing to the client.
b) Phone for a mammogram for the clients
immediately.
c) Explain that this could be benign or it could
mean something else. It needs to be further
investigated.
d) Nothing. It doesn’t mean a thing.
Nursing Practice 3
47)     A client is wearing a continuous
cardiac monitor, which begins to sound its
alarm. A nurse sees no
electrocardiographic complexes on the
screen. Which is the priority action of the
nurse?
a) Call a code
b) Call the health care provider.
c) Check the client status and lead placement.
d) Press the recorder button on the
electrocardiogram console.
48)     A client is having frequent premature
ventricular contractions. The nurse place
priority on assessment of which item?
a) Sensation of palpitations
b) Causative factors, such as caffeine
c) Precipitating factors, such as infection
d) Blood pressure and oxygen saturation
49)     The nurse is providing instructions to
a client with a diagnosis of hypertension
regarding high-sodium items to be avoided.
The nurse instructs the client to avoid
consuming which item?
a) Bananas
b) Broccoli
c) Antacids
d) Cantaloupe
50)     The nurse in the medical unit is
reviewing the laboratory test results for a
client who has been transferred from the
intensive care unit. The nurse notes that a
cardiac troponin T level essay was
performed while the client was in the
intensive care unit. The nurse determines
that this test was performed to assist in
diagnosing which condition?
a) Heart failure
b) Myocardial infarction
c) Atrial fibrillation
d) Ventricular tachycardia
51)     A client has history of chronic renal
failure and received hemodialysis
treatments three times per week through an
arteriovenous (AV) fistula in the left arm.
Which of the following interventions is
included in this client’s plan of care?
a) Keep the AV fistula site dry.
b) Keep the AV fistula wrapped in gauze
c) Take the blood pressure in the left arm
d) Assess the AV fistula for a bruit and thrill
52)     The client newly diagnosed with
chronic renal failure recently has
hemodialysis. Knowing that the client is at
risk for disequilibrium syndrome, the nurse
assesses the client during dialysis for:
a) Hypertension, Tachycardia, and fever
b) Hypotension, bradycardia, and hypothermia
c) Restlessness, irritability, and generalized
weakness
d) Headache, deteriorating level of
consciousness, and twitching.
53)     A client is in the acute phase of
rheumatoid arthritis. Which of the following
should the nurse identify as lowest priority
in the plan care?
a) Relieving pain.
b) Preserving joint function.
c) Maintaining usual ways of accomplishing
tasks.
d) Preventing joint deformity.
54)     A 25-year-old client taking
hydroxychloroquine (Plaquenil) for
rheumatoid arthritis difficulty seeing out of
her left eye. Correct interpretation of this
assessment finding indicates whish of the
following?
a) Development of a cataract
b) Possible retinal degeneration
c) Part of the disease process
d) A coincidental occurrence
55)     The Nurse is administering atenolol
(Tenormin) to a client. Which concurrent
drug does the nurse expect to most likely
cause an interaction?
a) ginseng herb
b) methyldopia (Aldomet)
c) an NSAID, such as aspirin 60)     Which of the following is a nursing
d) haloperidol (Haldol) priority when caring for a male patient with
a condom catheter?
56)     Select all of the signs and symptoms
of hyperthyroidism. a) Preventing the tubing from kinking to
maintain free urinary drainage
1. Cool skin                             b) Not removing the catheter for any reason
2. Thickened bodily hair         c) Fastening the condom tightly to prevent the
3. Heat intolerance possible ability of leakage
4. Constipation d) Maintaining bed rest at all times to prevent
5. Insomnia the catheter from slipping off
6. Increased appetite
a) 1, 2 and 4 61)     A patient has a nursing diagnosis of
b) 3, 5, 6 and 7 in paired urinary illumination related to
c) 3, 5, and 6 maturational enuresis. You recognize that
d) 2, 3, 5 and 7 your patient. Is which of the following?

57)     Select all of the risk factors that are a) An older adult that is 65 years of age is
associated with deep vein thrombosis. incontinent
1. The use of oral contraceptives       b) A child older than four years of age who has
2. Type B and O blood                        an voluntary urination
3. Rh negative blood c) A 12 month old child who is in voluntary
4. Obesity urination
5. Nulliparity d) A patient with Neurological damage resulting
6. Leukemia in bladder dysfunction

a) 1 and 4 only
b) 3 and 6 only Nursing Practice 4
c) 2 and 5 only 62)     Select the following fire emergency
d) 1 and 6 only interventions in correct sequential order.

58)     Which of the following terms did note 1. Pull the fire alarm 
a patient’s inability to void even though the 2. Rescue patients in danger
kidneys are producing urine that enters the 3. Contain the fire     
bladder? 4. Extinguish the fire

a) Urgency a) 1, 2, 3 and 4
b) Retention b) 4, 3, 2 and 1
c) Oliguria c) 3, 1, 2 and 4
d) Dysuria d) 2, 3, 1 and 4

59)     A patient taking Phenazopyridine 63)     You are preparing a sterile field for an
(pyridium, a urinary track analgesic) should operating room surgical procedure. When
be cautioned that her urine and may change should you stop the preparation of this
to what color? sterile field?

a) Pale yellow a) When you have placed a sterile item only 1

b) Green inch and 2 inches from the edge of the sterile
c) Orange red field
d) Brown b) When you have completely finished the field.
You cannot stop the set up until it is all done.
c) When you have accidentally poured a sterile
liquid into a container that was on the sterile
field
d) When you turn your upper body only away
from the field because the surgeon calls your
name
64)     Which type of burn leads to the
greatest degree of pain?
a) A first-degree burn
b) A third-degree burn
c) A second degree burn
d) A fourth-degree burn
65)     Avulsed teeth should be placed in:
a) Normal saline
b) Milk
c) Cold water
d) Warm water
66)     You are caring for a patient with
multiple -trauma. Of all these injuries and
conditions, it is the most serious?
a) A deviated trachea
b) Gross deformity of a lower extremity
c) Hematuria
d) Decreased bowel sounds
67)     Sutures and staples are typically
removed following surgery within:
a) 7 to 10 days if healing is considered
adequate
b) 10 to 14 days if healing is considered
adequate
c) 7 to 10 days if no further dressings are
needed.
d) 10 to 14 days if no further dressings are
needed.
68)     Which statement about glaucoma is
true and accurate?
a) Acute angle-closure glaucoma is an ocular
emergency.
b) Acute angle-closure glaucoma leads to the
loss of peripheral vision and tunnel vision.
c) Primary open-angle glaucoma leads to eye
pain, nausea, and vomiting, blurry vision and
halos.
d) Bubbles are implanted to protect the retina
from the glaucoma.
69)     You are calling for a four-year-old
female patient who was severely burned in
a house fire. How would you determine the
extent of this child’s burns?
a) By using the Lund and Browder chart.
b) By using the Rule of Nines.
c) By using the Rule of Tens
d) By using the Parkland Formula
70)     Tonometry is performed on the client
with a suspected diagnosis of glaucoma.
The nurse analyzes the test results as
documented in the client’s chart and
understands that normal intraocular
pressure is:
a) 2-7 mmHg
b) 22-30 mmHg
c) 10-21 mmHg
d) 31-35 mmHg
71)     Cataract surgery results in aphakia.
Which of the following statements best
describes this term?
a) Absence of the crystalline lens
b) A “keyhole” pupil
c) Loss of accommodation
d) Retinal detachment
72)     The client with glaucoma asks the
nurse is complete vision will return. The
most appropriate response is:
a) “Although some vision has been lost and
cannot be restored, further loss may be
prevented by adhering to the treatment plan.”
b) “Your vision will return as soon as the
medications begin to work.”
c) “Your vision will never return to normal.”
d) “Your vision loss is temporary and will return
in about 3-4 weeks.”
73)     For a client having an episode of
acute narrow-angle glaucoma, a nurse
expects to give which of the following
medications?
a) Acetazolamide (Diamox)
b) Furosemide (Lasix)
c) Atropine
d) Urokinase (Abbokinase)
74)     Which statement about Meniere’s
disease is accurate and true?
a) Meniere’s disease most commonly occurs
among members of the elderly population.
b) Meniere’s disease is insidious, and it always
affects both ears.
c) Meniere’s disease occurs with an
impairment of the second cranial nerve.
d) Antiemetic drugs are used for the treatment
of patients affected with Meniere’s disease.
75)     Which patient is most at risk for
Osgood-Schlatter disease?
a) An elderly female who is hospitalized with a
hip fracture and on bedrest
b) A middle aged male patient who has been
exposed to asbestos in the shipping industry
c) An adolescent who is physically active and
the captain of their soccer team
d) An infant of low birth weight and a
gestational age of 28 weeks
Nursing Practice 5
76)     The client is willing to go out of the
house for fear of “doing something crazy in
public.”
a) Agoraphobia
b) Claustrophobia
c) Social phobia
d) Hypochondriasis
77)     A nurse places an object on the hand
of a client with Alzheimer’s disease and
asks the client to identify the object. Which
term represents the client’s inability to
name the object  c) Acrophobia,a natural environment type of
a) Agnosia
b) Aphasia
c) Apraxia
d) Perseveration
78)     Which of the following symptoms is
not seen in dementia of the Alzheimer’s
type (DAT)
a) Agnosia
b) Aphasia
c) Apraxia
d) Agoraphobia
79)     A client is experiencing agnosia as a
result of vascular dementia. She is starting
at dinner and utencils without trying to eat.
Which intervention should the nurse
attempt first?
a) Pick up the fork and feed the client slowly
b) Say, “It’s time for you to start eating your
dinner.”
c) Hand the fork to the client and say, “Use this
fork to eat your green beans.”
d) Save the client’s dinner until her family
comes in to feed her.
80)     The physician orders risperidone
(Risperdal) for a client with Alzheimer’s
disease. The nurse anticipates
administering this medication to help
decrease which of the following behaviors?
a) Sleep disturbances.
b) Concomitant depression.
c) Agitation and assaultiveness.
d) Confusion and withdrawal.
81)     A client has a history of excessive
fear of water. What is the term that a nurse
should use to describe this specific phobia,
and under what subtype of this phobia, and
under what subtype is this phobia
identified?
a) Aquaphobia, a natural environment type of
phobia
b) Aquaphobia, a situational type of phobia
phobia
d) Acrophobia, a situational type of phobia
82)     A nursing instructor is teaching about
a specific phobia. Which student statement
should indicate that learning has occurred?
a) “These clients do not recognize that their
fear is excessive and rarely seek treatment.”
b) “These clients have a panic level of fear that
is overwhelming and unreasonable.”
c) “These clients experience symptoms that
mirror a cerebrovascular accident (CVA).”
d) “These clients experience the symptoms of
tachycardia, dysphagia, and diaphoresis.”
83)     The nursing instructor should
evaluate that learning has occurred when
the student knows that clients experiencing
phobias have a panic level of fear that is
overwhelming and unreasonable. Phobia is
fear cued by a specific object or situation in
which exposure to the stimuli produces an
immediate anxiety response. Following x-
rays of an injured wrist, the patient is
informed that it is badly sprained. In
teaching the patient to care for the injury,
the nurse tells the patient to:
a) apply a heating pad to reduce muscle
spasms.
b) wear an elastic compression bandage
continuously.
c) use pillows to keep the arm elevated above
the heart.
d) gently exercise the joint to prevent muscle
shortening.
84)     When evaluating the crutch-walking
technique of a patient with a right-leg long-
leg cast and no weight bearing on the right
leg, the nurse determines that the patient is
prepared to ambulate independently with
the crutches on observing that the patient:
a) uses the bedside chair to assist in balance
as needed when ambulating in the room.
b) keeps the padded area of the crutch firmly in
the axillary area when ambulating.
c) advances the right leg and both crutches
together and then advances the left leg.
d) moves the left crutch with the left leg and
then the right crutch with the right leg.
85)     A patient who has severe peripheral
arterial disease and ischemic foot ulcers is
upset with the health care provider’s
recommendation to have an above-the –
knee amputation. The patient tells the
nurse, “If they want to cut off my leg, they
should just shoot me instead. “The
appropriate response to the patient’s
statement is,
a) “Let’s talk about how you feel this surgery
will affect you.”
b) “If you do not want the surgery, you do not
have to have it.”
c) “I understand why you are upset, but there
really is no choice because your leg is so badly
diseased.”
d) “Many people are able to function normally
with a prosthesis after amputation, and you can
too.”
86)     On the first postoperative day, a
patient with a below–the–knee amputation
complains of pain in the amputated limb. An
appropriate action by the nurse is to.
a) administer prescribed opioids to relieve the
pain
b) explain the reasons for phantom limb pain.
c) loosen the compressions bandage to
decreased incisional pressure
d) remind the patient that this phantom pain will
diminish over time
87)     A patient undergoes a right below–
the–knee amputation with an immediate
prosthetic fitting. When the patient is
returned to the nursing unit, the nurse
should?
a) Check the surgical site for hemorrhage
b) Take the patients vital sign frequently
c) Keep the residual leg elevated on a pillow
d) Place the patient in a prone position
88) The nurse provides discharge
instructions to a patient with an above –the-
knee umputation who kill be fitted with a
prosthesis when healing is complete, and
the residual limb is well molded. The nurse 
a) “I should change the limb sock when it
becomes soiled or stretched out.”
b) “I should use lotion on the stump to prevent
drying and cracking of the skin.”
c) “I should elevate my residual limb on a pillow
2 or 3 times a day.”
d) “I should lay on my abdomen for 30 minutes
3 or 4 times a day.”
89)     A nurse is teaching a wellness class
and is covering the warning signs of stroke.
A patient asks, “What is the most important
thing for me to remember?” Which is an
appropriate response by the nurse?
a) “Know your family history.”
b) “Keep a list of your medications.”
c) “Be alert for sudden weakness or
numbness.”
d) “Call the hospital if you notice a gradual
onset of paralysis or confusion.”
90)     Which of the following is the priority
nursing diagnosis for a patient diagnosed
with a spinal cord injury?
a) Fluid Volume Deficit
b) Impaired Physical Mobility
c) Ineffective Airway Clearance
d) Altered tissue perfusion
91)     A post–stroke patient is going home
on oral Coumadin (warfarin). During
discharge teaching, which statement by the
patient reflects an understanding of the
effect of this medication?
a) “I will stop taking this medicine if I notice any
bruising.”
b) “I will not eat spinach whole I’m taking this
medicine.”
c) “It will be OK for me to eat anything, as long
as it is low fat.”
d) “I’ll check my blood pressure frequently
while taking this medication.”
92)     The nurse is teaching regarding risk
factors for stroke (CVA.) The greatest risk
factor is which of the following
a) Diabetes
b) Renal insufficiency
c) Heart disease
d) Hypertension
93)     A patient is admitted with signs of a
stroke (CVA). On admission, vital signs
were blood pressure 128/70. Pulse 68, and
respirations 20. Two hours later the patient
is not awake has a blood pressure of
170/70, pulse 52, and the left pupil is now
slower than the right pupil in reacting to
light. These findings suggest which of the
following?
a) impending brain death
b) decreasing intracranial pressure
c) stabilization of the patient’s condition
d) increased intracranial pressure
94)     A patient with a spinal cord injury at
the T1 level complaints of a severe
headache and an “anxious feeling.” Which
is the most appropriate initial reactions by
the nurse?
a) Try to calm the patient and make the
environment soothing.
b) Assess for a full bladder
c) Notify the healthcare provider
d) Prepare the patient for diagnostic
radiography
95)     A hospitalized patient has become
unresponsive. The left side of the body is
flaccid. The attending physician believes
the patient may have had a stroke (CVA).
What is the nurse’s priority intervention?
a) Move the patient to the critical care unit
b) Assess blood pressure
c) Assess the airway and breathing
d) Observe urinary output
96)     Selye’s adaptation theory can be used
to understand the relationship between
stressful events and the body’s response to
stress. Which of the following statements
best describes this relationship?
a) The body goes through predictable
responses regardless of the type of stressor
b) The body’s defenses become depleted from
stressful events
c) The body reacts differently when the stress
is psychological rather than physical
d) The body eventually adapts to any stress in
a positive manner
97)     A client is pacing and complains of
racing thought. The nurse asks the client if
something upsetting happened, and the d) Significant others are important to provide
client’s response is vague and not focused care and concern
on the nurse’s question. The nurse
assesses the client’s level of anxiety as:

a) Mild
b) Moderate
c) Severe
d) Panic
98)     When teaching a group of clients about
antianxiety medications, the nurse explains that
benzodiazepines affect which brain chemical?
a) Acetylcholine
b) GABA
c) Norepinephrine
d) Serotonin

99)     The nurse is assessing a client for

recent stressful life events. The nurse
recognizes that stressful life events are
both:

a) Desirable and growth promoting

b) Positive and negative
c) Undesirable and harmful
d) Predictable and controllable

100)     When teaching stress management

to clients, the nurse will most likely
advocate which belief as a method of
coping with stressful life events?

a) Avoidance of stress is an important goal for

living
b) Control over one’s response to stress is
possible
c) Most people have no control over their level
of stress