1.The nurse is working with older adult clients in an extended care facility.

To enhance the clients’

gustatory sense, the nurse should:(1 Point)

A. Mix foods together

B. Assist with oral hygiene

C. Provide foods of similar texture and consistency

D. Make sure foods are extremely spicy

2.The client was working in the kitchen and was splashed in the face with a caustic cleaning agent. His
eyes were affected, and he was brought to the hospital for treatment. After cleansing and evaluation,
his eyes were bandaged. When assisting this client who has temporary visual loss to eat, the nurse
should:(1 Point)

A. Feed the client the entire meal

B. Allow the client to experiment with foods

C. Orient the client to the location of the foods on the plate

D. Encourage the family to feed the client

3.A client is legally blind in both eyes. Which of the following is the most appropriate statement for the
nurse to make to the client regarding providing the client with assistance?(1 Point)

A. “I will walk in front of you, and you can hold onto my belt.”

B. “I know that you must need me to be your sighted guide to get around in this facility.”

C. “I will warn you of upcoming curbs or stairs.”

D. “I will get you a wheelchair so that I can move you around safely.”

4.With advancing age, which of the following normal physiological changes in sensory function occurs?(1
Point)

A. Decreased sensitivity to glare

B. Increased number of taste buds

C. Difficulty discriminating vowel sounds

D. Decreased sensitivity to pain

5.The nurse is working with a client with a moderate hearing impairment. To promote communication
with this client, the nurse should:(1 Point)

A. Use a louder tone of voice than normal

B. Use visual aids such as the hands and eyes when speaking

C. Approach a client quietly from behind before speaking

D. Select a public area to have a conversation

6.The client has experienced a cerebrovascular accident (stroke) with resultant expressive aphasia
(inability to express thoughts). The nurse promotes communication with this client by:(1 Point)

A. Speaking very loudly and slowly

B. Asking open-ended questions so the client can completely respond

C. Using a picture chart for the client’s responses

D. Using hand gestures to convey information to the client

7.Which of the following occupations poses the least risk for sensory alterations?(1 Point)

A. Waiter

B. Welder

C. Computer programmer

D. Construction worker

8.An older adult client in a nursing home has visual and hearing losses. The nurse is alert to which of the
following signs that represents the effects of sensory deprivation?(1 Point)

A. Diminished anxiety

B. Improved task completion

C. Hallucinations or delusions

D. Decreased need for physical stimulation

9.A home safety measure specific for a client with diminished olfactory sense is the use of:(1 Point)

A. Smoke detectors on all levels

B. Extra lighting in hallways

C. Amplified telephone receivers

D. Mild water heater temperatures

10.10. For a client with receptive aphasia (difficulty understanding), which one of the following nursing
interventions is the most effective?(1 Point)

A. Providing the client with a letter chart to use to answer complex questions

B. Using a system of simple gestures and repeated behaviors to communicate

C. Offering the client a notepad to write questions and concerns

D. Obtaining a referral for a speech therapist

11.A myringotomy is performed on a client in the ambulatory care center. The ambulatory care nurse
calls the client 24 hours after the procedure to evaluate the status of the client. The client reports to the
nurse that a small amount of brownish drainage has been coming from the ear. Which of the following
instructions would the nurse provide to the client?(1 Point)

A. contact the physician

B. lie on the unaffected side to prevent the drainage from occurring

C. continue to monitor the drainage because this is normal and may occur for 24 to 48 hours following
the surgery

D. place a cotton plug in the ear to absorb the drainage

12. A nurse assesses a client with a blunt head injury sustained in a motor vehicle accident and notes the
presence of bloody drainage from the auditory canal. Which of the following nursing actions would be
appropriate?(1 Point)

A. document the findings

B. place a gauze pad over the ear to absorb the drainage

C. contact the physician

D. continue to monitor the drainage

13.A nurse is performing an assessment of a client with mastoiditis. Which of the following assessment
findings would the nurse expect to note in the client?(1 Point)

A. a pink tympanic membrane on otoscopic examination

B. an elevated temperature

C. swelling behind the ear

D. a transparent and clear tympanic membrane on otoscopic examination

14.A nurse is performing an assessment of a client with an inner ear disorder. Which of the following
assessment questions will the nurse ask the client to elicit information regarding this disorder?(1 Point)

A. do you have any hearing loss?

B. do you have any itchiness in your ear?

C. have you ever noticed any swelling around the ear?

D. do you have any burning in the ear?

15.A home care nurse visits a client who has just been discharged from the hospital after a fenestration
procedure for the treatment of otosclerosis. Which of the following instructions will the nurse provide to
the client?(1 Point)

A. drink liquids through a straw for the next few weeks

B. showering is permitted but swimming is to be avoided

C. increase fluids, and take a stool softener daily

D. there are no limitations with activities with this type of surgery

16.Nurse Jay is performing wound care. Which of the following practices violates surgical asepsis?(1
Point)

A. Holding sterile objects above the waist

B. Considering a 1″ edge around the sterile field as being contaminated

C. Pouring solution onto a sterile field cloth

D. Opening the outermost flap of a sterile package away from the body

17. During the acute phase of a burn, the nurse in-charge should assess which of the following?(1 Point)

A. Client’s lifestyle

B. Alcohol use

C. Tobacco use

D. Circulatory status

18.Nurse Kate is changing a dressing and providing wound care. Which activity should she perform first?
(1 Point)

A. Assess the drainage in the dressing.

B. Slowly remove the soiled dressing

C. Wash hands thoroughly.

D. Put on latex gloves.

19.Nurse May is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention
should the nurse include in the plan of care?(1 Point)

A. Turn and reposition the client at least once every 8 hours.

B. Vigorously massage lotion into bony prominences.

C. Post a turning schedule at the client’s bedside.

D. Slide the client, rather than lifting, when turning.

20.Nurse Jane formulates a nursing diagnosis of Impaired physical mobility for a client with third-degree
burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should
add which “related-to” phrase?(1 Point)

A. Related to fat emboli

B. Related to infection

C. Related to femoral artery occlusion

D. Related to circumferential eschar

21.The nurse is assessing for the presence of cyanosis in a male dark-skinned client. The nurse
understands that which body area would provide the best assessment?(1 Point)

A. Lips
B. Sacrum

C. Earlobe

D. Back of the hands

22.Which of the following individuals is least likely to be at risk of developing psoriasis?(1 Point)

A. A 32 year-old-African American

B. A woman experiencing menopause

C. A client with a family history of the disorder

D. An individual who has experienced a significant amount of emotional distress

23.Which of the following clients would least likely be at risk of developing skin breakdown?(1 Point)

A. A client incontinent of urine feces

B. A client with chronic nutritional deficiencies

C. A client with decreased sensory perception

D. A client who is unable to move about and is confined to bed

24.The nurse prepares to care for a male client with acute cellulites of the lower leg. The nurse
anticipates that which of the following will be prescribed for the client?(1 Point)

A. Cold compress to the affected area

B. Warm compress to the affected area

C. Intermittent heat lamp treatments four times daily

D. Alternating hot and cold compresses continuously

25. The clinic nurse assesses the skin of a white characteristic is associated with this skin disorder?(1
Point)

A. Clear, thin nail beds

B. Red-purplish scaly lesions

C. Oily skin and no episodes of pruritus

D. Silvery-white scaly patches on the scalp, elbow, knees, and sacral regions

26.When planning care for a male client with burns on the upper torso, which nursing diagnosis should
take the highest priority?(1 Point)

A. Ineffective airway clearance related to edema of the respiratory passages

B. Impaired physical mobility related to the disease process

C. Disturbed sleep pattern related to facility environment

D. Risk for infection related to breaks in the skin

27.In a female client with burns on the legs, which nursing intervention helps prevent contractures?(1
Point)

A. Applying knee splints

B. Elevating the foot of the bed

C. Hyperextending the client’s palms

D. Performing shoulder range-of-motion exercises

28.A male client comes to the physician’s office for treatment of severe sunburn. The nurse takes this
opportunity to discuss the importance of protecting the skin from the sun’s damaging rays. Which
instruction would best prevent skin damage?(1 Point)

A. “Minimize sun exposure from 1 to 4 p.m. when the sun is strongest.”

B. “Use a sunscreen with a sun protection factor of 6 or higher.

C. “Apply sunscreen even on overcast days.”

D. “When at the beach, sit in the shade to prevent sunburn.”

29. A female client is brought to the emergency department with second- and third-degree burns on the
left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area
that has been burned?(1 Point)

A. 18%

B. 27%

C. 30%

D. 36%

30.Which nursing intervention can help a client maintain healthy skin?(1 Point)

A. Keep the client well hydrated.

B. Avoid bathing the client with mild soap.

C. Remove adhesive tape quickly from the skin.

D. Recommend wearing tight-fitting clothes in hot weather.

31.A male client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the
nurse expects to see which type of secondary lesion?(1 Point)

A. Scale

B. Crust

C. Ulcer

D. Scar

32.A female adult client with atopic dermatitis is prescribed a potent topical corticosteroid, to be
covered with an occlusive dressing. To address a potential client problem associated with this
treatment, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing
diagnosis statement, the nurse should add which “related-to” phrase?(1 Point)

A. Related to potential interactions between the topical corticosteroid and other prescribed drugs

B. Related to vasodilatory effects of the topical corticosteroid

C. Related to percutaneous absorption of the topical corticosteroid

D. Related to topical corticosteroid application to the face, neck, and intertriginous sites

33.A male client is diagnosed with herpes simplex. Which statement about herpes simplex infection is
true?(1 Point)
A. During early pregnancy, herpes simplex infection may cause spontaneous abortion or premature
delivery.

B. Genital herpes simplex lesions are painless, fluid-filled vesicles that ulcerate and heal in 3 to 7 days

C. Herpetic keratoconjunctivitis usually is bilateral and causes systemic symptoms.

D. A client with genital herpes lesions can have sexual contact but must use a condom.

34.A female client with a severe staphylococcal infection is receiving the aminoglycoside gentamicin
sulfate (Garamycin) by the I.V. route. The nurse should assess the client for which adverse reaction to
this drug?(1 Point)

A. Aplastic anemia

B. Ototoxicity

C. Cardiac arrhythmias

D. Seizures

35.A male client is diagnosed with primary herpes genitalis. Which instruction should the nurse provide?
(1 Point)

A. “Apply one applicator of terconazole intravaginally at bedtime for 7 days.”

B. “Apply one applicator of tioconazole intravaginally at bedtime for 7 days.”

C. “Apply acyclovir ointment to the lesions every 3 hours, six times a day for 7 days.”

D. “Apply sulconazole nitrate twice daily by massaging it gently into the lesions.”
36.The clinic nurse is preparing to test the visual acuity of a client using a Snellen chart. Which of the
following identifies the accurate procedure for this visual acuity test?(1 Point)

A. Both eyes are assessed together, followed by the assessment of the right and then the left eye.

B. The right eye is tested followed by the left eye, and then both eyes are tested.

C. The client is asked to stand at a distance of 40ft. from the chart and is asked to read the largest line on
the chart.

D. The client is asked to stand at a distance of 40ft from the chart and to read the line than can be read
200 ft away by an individual with unimpaired vision.

37.The clinic nurse notes that the following several eye examinations, the physician has documented a
diagnosis of legal blindness in the client’s chart. The nurse reviews the results of the Snellen’s chart test
expecting to note which of the following?(1 Point)

A. 20/20 vision

B. 20/40 vision

C. 20/60 vision

D. 20/200 vision

38.The client’s vision is tested with a Snellen’s chart. The results of the tests are documented as 20/60.
The nurse interprets this as:(1 Point)

A. The client can read at a distance of 60 feet while a client with normal vision can read at 20 feet.

B. The client is legally blind.

C. The client’s vision is normal

D. The client can read only at a distance of 20 feet while a client with normal vision can read at 60
feet.

39.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:
(1 Point)

A. 2-7 mmHg

B. 10-21 mmHg

C. 22-30 mmHg

D. 31-35 mmHg

40.The nurse is developing a plan of care for the client scheduled for cataract surgery. The nurse
documents which more appropriate nursing diagnosis in the plan of care?(1 Point)

Self-care deficit

Imbalanced nutrition

Disturbed sensory perception

Anxiety

41.The nurse is performing an assessment in a client with a suspected diagnosis of cataract. The chief
clinical manifestation that the nurse would expect to note in the early stages of cataract formation is:(1
Point)

A. Eye pain

B. Floating spots
C. Blurred vision

D. Diplopia

42.In preparation for cataract surgery, the nurse is to administer prescribed eye drops. The nurse
reviews the physicians orders, expecting which type of eye drops to be instilled?(1 Point)

A. An osmotic diuretic

B. A miotic agent

C. A mydriatic medication

D. A thiazide diuretic

43.During the early postoperative period, the client who had a cataract extraction complains of nausea
and severe eye pain over the operative site. The initial nursing action is to:(1 Point)

A. Call the physician

B. Administer the ordered main medication and antiemetic

C. Reassure the client that this is normal.

D. Turn the client on his or her operative side

44.The client is being discharged from the ambulatory care unit following cataract removal. The nurse
provides instructions regarding home care. Which of the following, if stated by the client, indicates an
understanding of the instructions?(1 Point)

A. “I will take Aspirin if I have any discomfort.”

B. “I will sleep on the side that I was operated on.”

C. “I will wear my eye shield at night and my glasses during the day.”

D. “I will not lift anything if it weighs more that 10 pounds.”

45. The client with glaucoma asks the nurse is complete vision will return. The most appropriate
response is:(1 Point)

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.”

46.The nurse is developing a teaching plan for the client with glaucoma. Which of the following
instructions would the nurse include in the plan of care?(1 Point)

A. Decrease fluid intake to control the intraocular pressure

B. Avoid overuse of the eyes

C. Decrease the amount of salt in the diet

D. Eye medications will need to be administered lifelong.

47.The nurse is performing an admission assessment on a client with a diagnosis of detached retina.
Which of the following is associated with this eye disorder?(1 Point)

A. Pain in the affected eye

B. Total loss of vision

C. A sense of a curtain falling across the field of vision

D. A yellow discoloration of the sclera.

48.The nurse is caring for a client with a diagnosis of detached retina. Which assessment sign would
indicate that bleeding has occurred as a result of the retinal detachment?(1 Point)

A. Complaints of a burst of black spots or floaters

B. A sudden sharp pain in the eye

C. Total loss of vision

D. A reddened conjunctiva

49.The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which
intervention is initiated immediately?(1 Point)

A. Notify the physician

B. Irrigate the eye with cold water

C. Apply ice to the affected eye

D. Accompany the client to the emergency room

50.The client arrives in the emergency room with a penetrating eye injury from wood chips while cutting
wood. The nurse assesses the eye and notes a piece of wood protruding from the eye, what is the initial
nursing action?(1 Point)
A. Remove the piece of wood using a sterile eye clamp

B. Apply an eye patch

C. Perform visual acuity tests

D. Irrigate the eye with sterile saline.

51.The overall outcome criteria for client with sensory perception alterations are: Select All that applies.

a. Maintain the function of existing senses

b. Performs ADL dependently and safely.

c. Prevent injury.

d. Sensory overload or deprivation prevention.(1 Point)

a. A and D

b. A and C

c. A, C, D

d. B,C,D

e. All of the above

52.What are receptors for hearing, located in the cochlea of the ear, they detect sound waves. They are
also receptors of equilibrium and balance and detect acceleration of the body and position of the head?
(1 Point)

a. Hammer, Anvil and Stirrup

b. Hair cells

c. Mechanoreceptors

d. Proprioceptors

53.Mrs. COVIDA complains to the nurse that she is feeling anxious. He states, "I'm just so tired of all
these tests they are doing, and it's so noisy here at night. Her pulse is 105 bpm, and his blood pressure is
140/70. Nursing actions should include which of the following?(1 Point)

A. Call the physician and obtain an order for an anti-anxiety medication for PRN use.

B. Just let the client verbalize his feeling until he stops talking.

C. Close the blinds, dim the lights, and ask the patient what other measures would help her rest.

D. Turn on the television to provide distraction

54.Kristine who is five years old due to abdominal pain, the nurse is about to assess her pain level.
Which assessment tool is the most useful?(1 Point)

A. Simple description pain intensity scale

B. 0-10 numeric pain scale

C. Faces pain-rating scale

D. McGill-Melzack pain questionnaire

55.A female client with genital herpes simplex is being treated in the outpatient department. The nurse
teaches her about measures that may prevent herpes recurrences and emphasizes the need for prompt
treatment if complications arise. Genital herpes simplex increases the risk of:(1 Point)
a. cancer of the ovaries.

b. cancer of the uterus.

c. cancer of the cervix.

d. cancer of the vagina.

56.Miguel accidentally fall from his bike while playing at the park and bleeding was noted. Which of the
following is the initial intervention for Miguel with external bleeding?(1 Point)

a. Direct Pressure

b. Elevation of the extremity

c. Pressure point control

d. Application of a tourniquet

57.For a client with herpes zoster is prescribed acyclovir (Zovirax), 200 mg P.O. every 4 hours while
awake. The nurse should inform the client that this drug may cause:(1 Point)

a. palpitations.

b. dizziness.

c. loose stool

d. metallic taste.

58.A client with second- and third-degree burns on the arms receives autografts. Two days later, the
nurse finds the client doing arm exercises. The nurse knows that this client should avoid exercise
because it may:(1 Point)
a. increase edema in the arms.

b. increase the amount of scarring.

c. decrease circulation to the fingers.

d. dislodge the autografts.

59.Ronnie is taking aspirin, which laboratory value should be reported to the physician?(1 Point)

a. Potassium 3.6 mEq/L

b. Hematocrit 41%

c. PT 14 seconds

d. BUN 20 mg/dL

60.Which client(s) would be appropriate to assign to a newly graduated RN, who has recently completed
orientation? Choose all that apply.(1 Point)

a. An anxious, chronic pain client who frequently uses the call button

b. A client with HIV who reports headache and abdominal and pleuritic chest pain

c. A client who is being discharged with a surgically implanted catheter

d. A client second day post-op who needs pain medication prior to dressing changes

61.Mr. Libron, husband of your patient, Sabana went to you and said, “Why can’t you give more
medicine? He is still having a lot of pain.” What is your best response?(1 Point)
a. “The doctor ordered the medicine to be given every 4 hours.”

b. “If the medication is given too frequently he could suffer ill effects.”

c. “Please tell your wife that I will be right there to check of her”

d. “Let’s wait about 30-40 minutes. If there is no relief I’ll call the doctor.”

62.Doctor Bean has ordered a placebo for a chronic pain client. You are newly hired nurse and you feel
very uncomfortable administering the medication. What is the first action that you should take?(1 Point)

a. Prepare the medication and hand it to the physician

b. Check the hospital policy regarding use of the placebo.

c. Follow a personal code of ethics and refuse to give it.

d. Contact the charge nurse for advice.

63. A client is being tapered off opioids and the nurse is watchful for signs of withdrawal. What are the
late signs of withdrawal? SELECT ALL THAT APPLIES

a. Fever

b. Nausea

c. Diaphoresis

d. Abdominal cramps(1 Point)

A. A,B,D
B. A,D,C

C. A,B,C

D. A,B,C,D

64. According to the World Health Organization (WHO) analgesic ladder, place the examples of drugs in
the order of usage. a. Morphine, hydromorphone, acetaminophen and lorazepam b. NSAIDs and
corticosteroids c. Codeine, oxycodone and diphenhydramine(1 Point)

a. B, A, C

b. C, A, B

c. B, C, A

d. A, B, C

None of the above

65.The Doctor has started titrating an analgesic to manage pain for your patient, what is the priority
goal?(1 Point)

a. Titrate upward until the client is pain free.

b. Titrate downwards to prevent toxicity.

c. Administer smallest dose that provides relief with the fewest side effects.

d. Ensure that the drug is adequate to meet the client’s subjective needs.

66.A client with chronic pain reports to you, the charge nurse, that the nurse have not been responding
to requests for pain medication. What is your initial action?(1 Point)
A.Check the MARs and nurses’ notes for the past several days.

B. Ask the nurse educator to give an in-service about pain management.

C. Perform a complete pain assessment and history on the client.

D. Have a conference with the nurses responsible for the care of this client

67. A male client is diagnosed with gonorrhea. When teaching the client about this disease, the nurse
should include which instruction?(1 Point)

a. “Avoid sexual intercourse until you’ve completed treatment, which takes 14 to 21 days.”

b. “Wash your hands thoroughly to avoid transferring the infection to your eyes.”

c. “If you have intercourse before treatment ends, tell sexual partners of your status and have them
wash well after intercourse.”

d. “If you don’t get treatment, you may develop meningitis and suffer widespread central nervous
system (CNS) damage.”

68.A female client exhibits s purplish bruise to the skin after a fall. The nurse would document this
finding most accurately using which of the following terms?(1 Point)

a. Ecchymosis

b. Purpura

c. Petechiae

d. Erythema
69.A female client with atopic dermatitis is prescribed medication for photochemotherapy. The nurse
teaches the client about the importance of protecting the skin from ultraviolet light before drug
administration and for 8 hours afterward and stresses the need to protect the eyes. After administering
medication for photochemotherapy, the client must protect the eyes for:(1 Point)

a. 4 hours.

b. 8 hours.

c. 24 hours.

d. 48 hours.

70.Nurse Josephine plans to administer dexamethasone cream to a client who has dermatitis over the
anterior chest How should the nurse apply this topical agent?(1 Point)

a. With a circular motion, to enhance absorption

b. With an upward motion, to increase blood supply to the affected area

c. In long, even, outward, and upward strokes in the direction opposite hair growth

d.In long, even, outward, and downward strokes in the direction of hair growth

71.The nurse primary concern for a male client with a solar burn of the chest, back, face, and arms is
seen in urgent care is?(1 Point)

a. fluid resuscitation.

b. infection.

c. body image.
d. pain management.

72.In an industrial accident, a male client that weighs 155 lb (70 kg) sustained full-thickness burns over
40% of his body. He’s in the burn unit receiving fluid resuscitation. Which observation shows that the
fluid resuscitation is benefiting the client?(1 Point)

a. A urine output consistently above 100 ml/hour

b. A weight gain of 4 lb (2 kg) in 24 hours

c. Body temperature readings all within normal limits

d. An electrocardiogram (ECG) showing no arrhythmias

73.The nurse is teaching a female client with a leg ulcer about tissue repair and wound healing. Which of
the following statements by the client indicates effective teaching?(1 Point)

a. “I’ll limit my intake of protein.”

b. “I’ll make sure that the bandage is wrapped tightly.”

c. “My foot should feel cold.”

d. “I’ll eat plenty of fruits and vegetables.”

74.Which of the following clients be at risk of developing skin breakdown? SATA

a. A client incontinent of urine feces

b. A client with chronic nutritional deficiencies

c. A client who is unable to move about and is confined to bed

d. A client with intact sensory perception(1 Point)

A. A,B,C

B. A,D,C

C. A,B

D. B,C,D

75.Nurse Daniela is implementing a teaching plan to a group of adolescents regarding the causes of
acne. Which of the following is an appropriate nursing statement regarding the cause of this disorder?(1
Point)

a. “Acne is caused by oily skin”

b. “The actual cause is not known”

c. “Acne is caused by eating chocolate”

d. “Acne is caused as a result of exposure to heat and humidity”

76.A client with diabetic neuropathy reports a burning, electrical-type in the lower extremities that is
not responding to NSAIDs. You anticipate that the physician will order which adjuvant medication for
this type of pain?(1 Point)

A.Corticosteroids

B. Amitriptyline (Elavil)

C. Methylphenidate (Ritalin)

D. Lorazepam (Ativan)
77. Charge nurse Nath is reviewing the charts of clients who were assigned to staff nurse Josline, a newly
graduated RN. Josline has correctly charted dose and time of medication, but there is no documentation
regarding non-pharmaceutical measures. What action should you take first?(1 Point)

A. Make a note in the nurse’s file and continue to observe clinical performance

B. Refer the new nurse to the in-service education department.

C. Quiz the nurse about knowledge of pain management

D. Give praise for the correct dose and time and discuss the deficits in charting.

78. Nurse Debbie is caring for a wheelchair-bound client. Which piece of equipment impedes circulation
to the area it’s meant to protect?(1 Point)

a. Polyurethane foam mattress

b. Gel flotation pad

c. Water bed

d. Ring or donut

79.In teaching non-pharmaceutical alternatives, which topic could you delegate to an experienced
LPN/LVN, who will function under your continued support and supervision?(1 Point)

a. Therapeutic touch

b. Use of heat and cold applications

c. Meditation
d. Transcutaneous electrical nerve stimulation

80.Which non-pharmacological measure is particularly useful for a client with acute pancreatitis?(1
Point)

a. Diversional therapy, such as playing cards or board games

b. Massage of back and neck with warmed lotion

c. Side-lying position with knees to chest and pillow against abdomen

d. Transcutaneous electrical nerve stimulation (TENS)

81.An older client’s physical examination reveals the presence of a number of bright red-colored lesions
scattered on the trunk and tights. The nurse interprets that this indicates which of the following lesions
due to alterations in blood vessels of the skin?(1 Point)

a. Cherry angioma

b. Spider angioma

c. Venous star

d. Purpura

82.Which of the following are characteristics of a normal sensory perception? SATA

a. VISION- visual acuity of 20/20, partial field of vision and tricolor ( red, green, blue )

b. HEARING- auditory of sounds at an intensity of 0 to 100 dB at frequencies of 125 to 8,000 cycles

per second.

c. SMELL- discrimination of primary odors such as floral, pepper minty and pungent.

d. SOMATIC- touch, pressure, vibration, position, tickling, temperature and pain are being
identified.(1 Point)
A. A,B,C

B. B, D

C. C,D

D. B,C,D

83.A 60-year-old client is being discharged from the same day surgery after having cataracts removed
from the right eye. Which of the following discharge summary does the nurse given? Select all that
applies.(1 Point)

a. Do not sleep on operative side

b. Do not rub or place pressure on the eyes.

c. Resumes all activities as before.

d. wear eye shield throughout the day and remove only at nighttime.

84.Which of the following describes hyphema?(1 Point)

a. Opacity of the lens that distorts the image projected onto the retina and that can progress to
blindness.

b. The presence of blood in the anterior chamber as a result of injury.

c. increased intraocular pressure because of inadequate drainage of aqueous humor.

d. Occurs when the layer of the retina separate because of accumulation of fluid between them, or
when both retinal layers elevate away from the choroid as a result of tumor.
85.A client arrives in the ER following an automobile accident. The client’s forehead hit the steering
wheel, and a hyphema is diagnosed. A nurse places the client in which position?(1 Point)

a. Semi- Fowler’s on the rest.

b. Flat on bed rest

c. Lateral on the affected side.

d. Lateral on the unaffected side.

86.A nurse would expect a a patient who has a cataract to report which of the following symptoms?(1
Point)

a. Decreased Color perception

b. Loss of peripheral vision

c. Halos around the lights

d. Headaches

87.Which of the following statements indicates that a client needs additional teaching after cataract
surgery?(1 Point)

A. “I’ll avoid eating until nausea sudsides.”

B. “I can’t wait to pick up my grand daughter.”

C. “I’ll avoid bending to tie over my shoelaces.”

D. “I’ll avoid touching the dropper to my eye when using my eyedrops.”

88. Which of the following in an effective technique of communicating with a hearing impaired client?(1
Point)

A. Speak slowly in a low tone of voice

B. Speak slowly in a loud voice

C. Speak slowly and try to overemphasize words.

D. Speak slowly and directly in front of the client.

89.A client who is complaining of tinnitus is describing a symptoms that is(1 Point)

a. Objective

b. Subjective

c. functional

d. Prodromal

90.Nurse Kathlyn is admitting patient to the hospital with a diagnosis of Meniere’s disease. Which of the
following assessment questions would elicit information specific to the attacks that occur with this
disorder?(1 Point)

A. Do you have a feeling of fullness in your ear?

B. Are you having any headaches?

C. Do you feel unusually tired?

D. Do you have difficulty sleeping at night?

91.Nurse Raphie is preparing a plan of care for patient fattie who is experiencing severe vertigo. Which
nursing intervention should He include to assist patient fattie in controlling the vertigo?(1 Point)

a. Instruct her to cut down on cigarrettte smoking

b. Encourage her to increase the daily fluid intake

c. Encourage her to avoid sudden head movements

d. Instruct her to increase the amount of sodium in the diet.

92. For the nursing care plan for patient fattie, the nursing diagnosis that would take priority would be:(1
Point)

A. Social Isolation related to anxiety

B. Risk for injury related to falls

C. Risk for deficient fluid intake related to weakness

D. Nutrition; less than body requirements related to fatigue.

93.Nurse Abbie documents the presence of a scab on a client’s deep wound. The nurse identifies this as
which phase of wound healing?(1 Point)

a. Inflammatory

b. Migratory

c. Proliferative

d. Maturation
94.Bebang has cellulites of her lower leg has had cultures done on the affected area. The nurse reading
the culture report understands that which of the following organisms is not part of the normal flora of
the skin?(1 Point)

a. Staphylococcus epidermidis

b. Staphylococcus aureus

c. Escherichia coli (E. coli)

d. Candida albicans

95. Following a full-thickness (third-degree) burn of his left arm, a male client is treated with artificial
skin. The client understands postoperative care of artificial skin when he states that during the first 7
days after the procedure, he will restrict:(1 Point)

a. range of motion.

b. protein intake.

c. going outdoors.

d. fluid ingestion.

96.A nurse is reviewing the medical record of a male client to be admitted to the nursing unit and notes
documentation of reticular skin lesions. The nurse expects that these lesions will appear to be:(1 Point)

a. Ring-shaped

b. Linear

c. Shaped like an arc

d. Net-like appearance

97.Dr. Martinez prescribes an emollient for a client with pruritus of recent onset. The client asks why the
emollient should be applied immediately after a bath or shower. How should the nurse respond?(1
Point)

a. “This makes the skin feel soft.”

b. “This prevents evaporation of water from the hydrated epidermis.”

c. “This minimizes cracking of the dermis.”

d. “This prevents inflammation of the skin.”

98.The nurse is reviewing the healthcare record of a male clients scheduled to be seen at the health care
clinic. The nurse determines that which of the following individuals is at the greatest risk for
development of an integumentary disorder?(1 Point)

a. An adolescent

b. An older female

c. A physical education teacher

d. An outdoor construction worker

99.Behaviors that would alert the nurse to a possible hearing deficit in the patient would be (Select all
that apply)(1 Point)

A. Watching the speaker’s mouth

B. Giving inappropriate answers to questions.

C. Complaining about people muttering and mumbling

D. Not responding when spoken to

E. Turning the good ear to the speaker.

100.Nerve deafness would most likely result from an injury or infection that damaged the:(1 Point)

A. Vagus Nerve

B. Cochlear nerve

C. Vestibular Nerve

D. Trigeminal nerve