Name: Section: Date: Instruction: Please encircle the letter. 1.

Nurse Mitch is providing post-procedure care for a client who underwent percutaneous lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. Nurse Mitch should instruct the client to: A. limit oral fluid intake for 1 to 2 weeks B. report the presence of fine, sand-like particles through the nephrostomy tube. C. Notify the physician about cloudy or foul-smelling urine D. Report bright pink urine within 24 hours after the procedure 2. A client with a serum glucose level of 618 mg/dl is admitted to the facility. He s awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6 F (38.1 C), heart rate of 116 beats/minute, and blood pressure of 108/70 mm Hg. Based on these assessment findings, which nursing diagnosis takes the highest priority? A. deficient fluid volume related to osmotic diuresis B. decreased cardiac output related to elevated heart rate C. imbalanced nutrition: Less than body requirements related to insulin deficiency D. ineffective thermoregulation related to dehydration 3. A Client is scheduled to have a descending colostomy. He s very anxious and has many questions regarding the surgical procedure, care of stoma, and lifestyle changes. It would be most appropriate for the nurse to make a referral to which member of the health care team? A. Social worker B. registered dietician C. occupational therapist D. enterostomal nurse therapist 4. Before weaning a client from a ventilator, which assessment parameter is most important for nurse Jelliane to review? A. fluid intake for the last 24 hours B. baseline arterial blood gas (ABG) levels C. prior outcomes of weaning D. electrocardiogram (ECG) results 5. Which assessment finding indicates dehydration? A. Tenting of chest skin when pinched. B. Rapid filling of hand veins. C. A pulse that isn t easily obliterated. D. Neck vein distention 6. A client is chronically short of breath and yet has normal lung ventilation, clear lungs, and an arterial oxygen saturation (SaO2) 96% or better. The client most likely has: A. poor peripheral perfusion B. a possible Hematologic problem C. a psychosomatic disorder D. left-sided heart failure 7. Nurse Ferlyn is reviewing the laboratory report of a client who underwent a bone marrow biopsy. The finding that would most strongly support a diagnosis of acute leukemia is the existence of a large number of immature: A. lymphocytes B. neutrophils C. macrophages D. leukocytes 8. A client with a forceful, pounding heartbeat is diagnosed with mitral valve prolapse. This patient should avoid which of the following? A. high volumes of fluid intake B. aerobic exercise programs C. caffeine-containing products D. foods rich in protein 9. Nurse Charisma is teaching a client with chronic bronchitis about breathing exercises. Which of the following should nurse Charisma include in the teaching? A. Make inhalation longer than exhalation. B. Exhale through an open mouth. C. Use diaphragmatic breathing.

D. Use chest breathing. 10. Nurse Makiling is caring for a client who has a tracheostomy and temperature of 39 C. Which intervention will most likely lower the client s arterial blood oxygen saturation? A. Endotracheal suctioning B. Encouragement of coughing C. Use of cooling blanket D. Incentive spirometry 11. Hemoptysis may be present in the client with a pulmonary embolism because of which of the following reasons? a. Alveolar damage in the infracted area b. Involvement of major blood vessels in the occluded area c. Loss of lung parenchyma d. Loss of lung tissue 12. Nurse Darryl is caring for a bedridden, elderly adult. To prevent pressure ulcers, which intervention should nurse Darryl include in the plan of care? A. Turn and reposition the client a minimum of 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. 13. When the nurse performs a neurologic assessment on Kimmy, her pupils are dilated and don t respond to light. A. glaucoma B. damage to the third cranial nerve C. damage to the lumbar spine D. Bell s palsy 14. For a client with a head injury whose neck has been stabilized, the preferred bed position is: A. Trendelenburg s B. 30-degree head elevation C. flat D. side-lying 15. After a laryngectomy, the most important equipment to place at the client s bedside would be: A. Suction equipment B. Humidified oxygen C. A nonelectric call bell D. A cold-stream vaporizer 16. A urinary tract infection is a potential danger with an indwelling catheter. Nurse Ferlyn can best plan to avoid this complication by: A. Assessing urine specific gravity B. Maintaining the ordered hydration C. Collecting a weekly urine specimen D. Emptying the drainage bag frequently 17. A client has sustained a fractured right femur in a fall on stairs. Nurse Charisma with the emergency response team assess for signs of circulatory impairment by: A. Turning the client to side lying position B. Asking the client to cough and deep breathe C. Taking the client s pedal pulse in the affected limb D. Instructing the client to wiggle the toes of the right foot 18. After a mastectomy, clients may feel incomplete as women. The statement that should alert Nurse Darryl to this feeling would be: A. I can t wait to see all my friends again B. I feel washed out; there isn t much left C. I can t wait to get home to see my grandchild D. My husband plans for me to recuperate at our daughter s home 19. Nurse Jelliane is aware that teaching about colostomy care is understood when the client states, I will contact my physician and report__ . A. If I notice a loss of sensation to touch in the stoma tissue B. When mucus is passed from the stoma between irrigations C. The expulsion of flatus while the irrigating fluid is running out D. If I have difficulty in inserting the irrigating tube into the stoma

20. Nurse Mitch observes that there is blood coming from the client s ear after head injury. Nurse MItch should: A. Turn the client to the unaffected side B. Cleanse the client s ear with sterile gauze C. Test the drainage from the client s ear with Dextrostix D. Place sterile cotton loosely in the external ear of the client 21. A pain scale is used to assess the degree of pain. The client rates the pain as an 8 on a scale of 10 before medication and a 7 on a scale of 10 after being medicated. Nurse Edward determines that the: A. Client has a low pain tolerance B. Medication is not adequately effective C. Medication has adequately decreased the pain level D. Client needs more education about the use of the pain scale 22. When caring for a patient with a pneumothorax, who has a chest tube in place, Nurse Caroline should plan to: A. Administer cough suppressants at appropriate intervals as ordered B. Empty and measure the drainage in the collection chamber each shift C. Apply clamps below the insertion site when ever getting the client out of bed D. Encourage coughing, deep breathing, and range of motion to the arm on the affected side 23. Which procedure or practice requires surgical asepsis? A. Hand washing B. Nasogastric tube irrigation C. I.V. cannula insertion D. Colostomy irrigation 24. The nurse is performing wound care using surgical asepsis. Which of the following practices violates surgical asepsis? A. Holding sterile objects above the waist B. Pouring solution onto a sterile field cloth C. Considering a 1" (2.5-cm) edge around the sterile field contaminated D. Opening the outermost flap of a sterile package away from the body 25. Aya who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the Patient Aya avoid pressure ulcers, Nurse Lila should: a. Turn him frequently. b. Perform passive range-of-motion (ROM) exercises. c. Reduce the client's fluid intake. d. Encourage the client to use a footboard. . 26. Lucy has stomatitis. To promote oral hygiene and comfort, the nurse Mary should: a. Provide frequent mouthwash with normal saline. b. Apply viscous Lidocaine to oral ulcers as needed. c. Use lemon glycerine swabs every 2 hours. d. Rinse mouth with Hydrogen Peroxide. 27. The term blue bloater refers to a male client which of the following conditions? a. Adult respiratory distress syndrome (ARDS) b. Asthma c. Chronic obstructive bronchitis d. Emphysema 28. The term pink puffer refers to the female client with which of the following conditions? a. Adult respiratory distress syndrome (ARDS) b. Asthma c. Chronic obstructive bronchitis d. Emphysema 29. Nurse Rose is aware that the statement that best explains why furosemide (Lasix) is administered to treat hypertension is: a. It dilates peripheral blood vessels. b. It decreases sympathetic cardioacceleration. c. It inhibits the angiotensin-coverting enzymes d. It inhibits reabsorption of sodium and water in the loop of Henle. 30. Claire is diagnosed with osteoporosis. Which electrolytes are involved in the development of this disorder? a. Calcium and sodium b. Calcium and phosphorous c. Phosphorous and potassium d. Potassium and sodium