Comprehensive Review of the Nclex by Saunders 3rd Ed. (Autosaved)
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COMPREHENSIVE REVIEW OF THE NCLEX – RN
EXAMINATION THIRD(3rd
) EDITION
QUESTIONS AND ANSWERS with RATIONALE
1. The nurse is assessing the child with a suspecteddiagnosis of appendicitis. In assessing the intensity
child at McBurney’s point. In performing this
assessment, the nurse knows that McBurney’s point
is located midway between the
1. Right anterior inferior iliac crest and the
umbilicus.
2. Left anterior superior iliac crest and the
umbilicus.
3. Right anterior superior iliac crest and the
umbilicus.
4. Left anterior superior iliac crest and theumbilicus.
ANSWER: 3
Rationale: McBurney’s point is midway between the
right anterior superior iliac crest and the umbilicus.
McBurney’s point is usually the location of greatest
pain in the child with appendicitis.
2. The nurse is caring for a client with a burn injury
to the lower legs. Nitrofurazone (furacin) is
prescribed to be applied to the sites of injury. Thenurse documents which of the following in the plan
of care as the appropriate method to apply this
medication?
1. Apply saline soaked dressings over the
medication.
2. Apply 1-inch film directly to the burn sites.
3. Apply 1∕16-inch film directly to the burn sites.
4. Apply 1/2-inch film directly to the burn sites
after cleansing the wounds.
ANSWER: 3
Rationale: Nitrofurazone (Furacin) is applied
topically to the burn and has a broad spectrum of
antibiotic activity. Nitrofurazone is used in burns in
which bacterial resistance to other agents is a real or
potential problems. A film of 1/16 inch is applied
directly to the burn. Saline-soaked dressings are not
used.
3. A client suspected of having an abdominal tumor
is scheduled for a computerized tomography scan
with dye injection. The nurse tells the client that
1. The test may be painful.
2. The dye injected may cause a warm flushing
sensation. 3. Fluids will be restricted following the test.
4. The test takes about 2 hours.
ANSWER: 2
4. The nurse is caring for a client whose magnesium
level is 3.5 mg/dL. Which assessment sign/symptom
would the nurse most likely expect to note in the
client based on this magnesium level?
1. Tetany
2. Twitches
3. Positive trousseau’s sign
4. Loss of deep tendon reflex
5. The nurse is caring for a client with a diagnosis ofhyperthyroidism. Laboratory studies are performed,
and the serum calcium level is 12 mg/dL. Which
medication would the nurse anticipate to be
prescribed for the client?
1. Calcium gluconate
2. Calcium chloride
3. Calcitonin (Calcimar)
4. Large doses of vitamin D
6. The nurse prepares to administer sodiumpolystyrene sulfonate (Kayexalate) to the client.
Before administering the medication, the nurse
reviews the action of the medication and
understands that it releases
1. Bicarbonate in exchange primarily for sodium
ions.
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2. Sodium ions in exchange primarily for
bicarbonate ions.
3. Sodium ions in exchange primarily for
potassium ions.
4. Potassium ions in exchange primarily for
sodium ions.
7. Which of the following clients is least likely at risk
for the development of third spacing?
1. The client with cirrhosis
2. The client with diabetes mellitus.
3. The client with liver failure
4. The client with renal failure
8. The nurse is preparing to care for a clientfollowing a gastroscopy procedure. The nurse
includes which most appropriate component in the
nursing care plan?
1. Place the client in supine position to provide
comfort.
2. Monitor the client’s vital signs every hour for 4
hours.
3. Provide saline gargles immediately on return to
the unit to aid in comfort.
4. Check the gag reflex by using a tongue
depressor to stroke the back of client’s throat.
9. Intravenous Ringer’s lactate solution is prescribed
for the postoperative client. The nursing instructor
asks the nursing student who is caring for the client
about the tonicity of the prescribed intravenous
solution. The nursing student responds correctly by
stating that this solution is
1. Isotonic.
2. Normotonic.
3. Hypotonic.4. Hypertonic.
10. The nurse reviews the arterial blood gas results
of a client with Guillain-Barre syndrome. The pH is
7.35 and the PCO2 is 50mmHg. The nurse interprets
that this client is experiencing which acid-base
imbalance?
1. Respiratory acidosis
2. Respiratory alkalosis
3. Metabolic acidosis
4. Metabolic alkalosis
11. The client is admitted 24 hours following an
aspirin overdose. The nurse assesses this client for
which signs and symptoms indicating the acid-base
disturbance that can occur in the client?
1. Bradycardia and Hyperactivity
2. Restlessness, confusion and a positive
trousseau’s sign
3. Headache, nausea, vomiting and diarrhea
4. Bradypnea, dizziness and paresthesias
12. The adult client with hepatic encephalopathy has
a serum ammonia level of 95 mcg/dL and receives
treatment with lactulose (Chronulac). The nurse
would evaluate that the client had the best and most
realistic response, if the serum ammonia level
changed to which of the following after medication
administration?
1. 80mcg/dL
2. 60mcg/dL3. 10mcg/dL
4. 5mcg/Dl
13. The client who suffered a crush injury to the leg
has a highly positive urine myoglobin level. The
nurse assesses this particular client carefully for
signs of
1. Cerebrovascular accident
2. Acute tubular necrosis
3. Respiratory failure4. Myocardial infarction
14. The adult male client admitted to the hospital
with shock has received fluid volume replacement .
The nurse evaluates that the client has had adequate
fluid resuscitation if the client’s repeat hematocrit
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level has decreased to which of the following values
in the normal range?
1. 56%
2. 48%
3. 39%
4. 34%
15. The nurse is formulating a plan of care for a
client receiving enteral feedings. Which nursing
diagnosis is of highest priority for this client?
1. Imbalanced Nutrition, Less Than Body
Requirements.
2. Risk for aspiration
3. Risk for Deficient Fluid Volume
4. Diarrhea
16. A Client who has gastrostomy tube for feeding
refuses to participate in the plan of care, will not
make eye contact, and does not speak to the family
or visitors. The nurse assesses that this client is using
which type of coping mechanism?
1. Self-control
2. Problem-solving
3. Accepting responsibility
4. Distancing
17. The nurse conducting a weight loss program
prepares to monitor a client’s weight loss. What
method would assess the effectiveness of weight
loss most accurately?
1. Daily weights
2. Serum protein levels
3. Calorie counts
4. Daily intake and output
18. The clinic nurse is monitoring a client with
anorexia nervosa. Which statement if made by a
client would indicate to the nurse that treatment has
been effective?
1. ”I no longer have a weight problem.”
2. “I don’t want to starve myself anymore.”
3. “I’ll eat until I don’t feel hungry.”
4. “My friends and I went out to lunch today.”
19. The nurse is teaching the postgastrectomy client
about measures to prevent dumping syndrome.
Which statement by the client indicates a need forfurther teaching?
1. “I need to lie down after eating.”
2. “I need to drink liquids with meals.”
3. ”I need to eat small meals six times daily.”
4. “I need to avoid concentrated sweets.”
20. A client has been diagnosed with pernicious
anemia. In planning care for the client, the nurse
anticipates that the client will be treated with
1. Thiamine2. Iron
3. Vitamin B12
4. Folic acid
21. An older postoperative client has been tolerating
a full liquid diet, and the nurse plans to advance the
diet to solid food as prescribed. Which assessment is
most important for the nurse to make before
advancing the diet to solids?
1. Food preferences2. Cultural preferences
3. Preference of bowel sounds
4. Ability to chew
22. The client with diabetes mellitus has been
instructed in the dietary exchange system. The client
ask the nurse if bacon is allowed in the diet. Which
nursing response is most appropriate?
1. “Bacon is much too high in fat.”
2. “Bacon is not allowed.” 3. “One strip of bacon may be eaten if you
eliminate one teaspoon of butter.”
4. “Bacon may be eaten if you eliminate one
meat item from your diet.”
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23. The client with heart disease is provided
instructions regarding a low-fat diet. The nurse
determines that the client understands the diet if
the client states that the food item to avoid is
1. Apples.
2. Oranges.3. Avocado.
4. Cherries.
24. A client with liver cancer who is receiving
chemotherapy tells the nurse that some foods on
the meal tray taste bitter. The nurse would try to
limit which food that is most l ikely to cause this taste
for the client?
1. Beef
2. Potatoes3. Custard
4. Cantaloupe
25. A nursing student is caring for a client who has
been admitted to the hospital with malnutrition. The
student is reviewing the results of the various
laboratory tests performed on the client with the
nursing instructor. Which statement if made by the
nursing student indicates an understanding of the
interpretation of the results?1. “An elevated creatinine level indicates
respiratory problems.”
2. “A normal hemoglobin level indicates that iron
and protein intake is sufficient.”
3. “An elevated albumin level indicates a definite
dehydration.”
4. “A normal red blood cell level indicates
adequate vitamin B6 intake”
26. The nurse notes that the infant with diagnosis ofhydrocephalus has a head that is heavier than the
average infant. The nurse determines that special
safety precautions are needed when moving the
infant. Which statement would the nurse include in
the discharge teaching with the parents to reflect
this safety need?
1. “When picking up your infant, support the
infants neck and head with the open palm of your
hand.”
2. “Feed your infant in a side-lying position.”
3. “Place a helmet on your infant when your in
bed.”4. “Hyperextand your infant’s head with a rolled
blanket under the neck area.”
27. The nurse is performing an admission
assessment on a child with a seizure disorder. The
nurse is interviewing the child’s parents to
determine their adjustment to caring for their child
who has a chronic illness. Which statement if made
by the parents would indicate a need for further
teaching?1. “Our child is involved in a swim program with
neighbors and friends.”
2. “Our child sleeps in our bedroom at night.”
3. “Our babysitter just completed
cardiopulmonary resuscitation training.”
4. “We worry about injuries when our child has a
seizure.”
28. The nurse is reviewing the results of a serum
level drawn from a child who is receivingcarbamazepine(Tegretol) for the control of seizures.
The results indicate a level of 10 mcg/mL. The nurse
analyzes the results and anticipates that the
physician will prescribe.
1. An increase of the dose of the medication.
2. A decrease of the dose of the medication.
3. Discontinuation of the medication.
4. Continuation of the presently prescribed
dosage.
29. The nursing student is asked to describe the
corpus of the uterus. Which of the following
responses, if made by the student, indicates an
understanding of the anatomy of the uterus?
1. “The corpus is the lower portion of the uterus.”
2. “The corpus is the upper part of the uterus.”
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3. “The corpus is the area where the cervix meet
the external os.”
4. “The corpus is the area when the vagina meets
the uterus.”
30. The nurse instruct the client with diabetes
mellitus about blood glucose monitoring and
monitoring for signs of hypoglycemia. The nurse
informs the client that hypoglycemia is a blood
glucose level of less than
1. 120 mg/dL.
2. 110 mg/dL.
3. 90 mg/dL.
4. 60 mg/dL.
31. The client newly diagnosed with diabetes
mellitus is instructed by the physician to obtainglucagon for emergency home use. The client asks
the home care nurse about the purpose of the
medication. The nurse instructs the client that the
purpose of the medication is to treat
1. Hypoglycemia from insulin overdose.
2. Hyperglycemia from insufficient insulin.
3. Lipoatrophy from insulin injections.
4. Lipohypertrophy from inadequate insulin
absorption.
32. The nurse is providing care to a Cuban American
client who is terminally ill. Numerous family
members are present most of the time, and many of
the family members are emotional. The most
appropriate action is to
1. Restrict the numbers of family members
visiting at one time.
2. Inform the family that emotional outbursts are
to be avoided.
3. Request permission to move the client to a
private room and allow the family members to visit.4. Contact the physician to speak to the family
regarding their behaviors.
33. The nurse is instructing a postpartum client with
endometritis about preventing the spread of
infection to the newborn infant. The nurse would tell
the client that
1. Hands should be washed thoroughly before
holding the infant.
2. The newborn infant will not be allowed in the
mother’s room at all. 3. There is no danger of the newborn contracting
the disease.
4. Visitors are not allowed to hold the baby.
34. A client presents to the emergency department
with upper gastrointestinal bleeding and is in
moderate distress. In planning care, which nursing
action would be the first priority for this client?
1. Thorough investigation of precipitating events
2. Insertion of a nasogastric tube and hematest of
emesis
3. Complete abdominal examination
4. Assessment of vital signs.
35. The nurse is caring for a client with possible
cholelithiasis who is being prepared for an
intravenous cholangiogram, and the nurse teaches
the client about the procedure. Which client
statement indicates that the client understands thepurpose of this test?
1. “They are going to ‘look at’ my gallbladder and
ducts.”
2. “This procedure will drain my gallbladder.”
3. “My gallbladder will be irrigated.”
4. “They will put medication in my gallbladder.”
36. The nurse provides instructions to a
malnourished client regarding iron supplementation
during pregnancy. Which statement if made by theclient would indicate an understanding of the
instructions?
1. “The iron is best absorbed if taken with orange
juice.”
2. Meat does not provide iron and should be
avoided.”
3. “Iron supplements will give me diarrhea.”
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4. “My body has all the iron it needs, and I don’t
need to take supplements.”
37. The nurse has give discharge instructions to the
client who has underwent vein ligation and strippingearly in the day. The nurse evaluates that the client
understands activity and positioning limitations if
the client states that it is most appropriate to
1. Lie down with the legs elevated and avoid
sitting.
2. Cross the legs at the ankle only, but not at the
knee.
3. Sit in the chair 3 times a day for 3 hours at a
time.
4. Walk upright for as much as possible each day.
38. Octreotide acetate (Sandostatin) is prescribed forthe client with acromegaly. The nurse monitors the
client, knowing that which side effect is associated
with the administration of this medication?
1. Constipation
2. Polyuria
3. Abdominal pain
4. Hypotension
39. Levothyroxine (Synthroid) is prescribed for a
client diagnosed with hypothyroidism. The nursereviews the client’s records and notes that the client
presently is taking warfarin (Caumadin). The nurse
contacts the physician, anticipating that the
physician will prescribe which of the following?
1. An increased dosage of warfarin.
2. A decreased dosage of warfarin.
3. An increased dosage of levothyroxine.
4. A decreased dosage of levothyroxine.
40. The nurse is teaching the client with emphysemaabout positions that help breathing during dyspneic
episodes. The nurse instruct the client to avoid
which of the following positions, which will
aggravate breathing?
1. Sitting up with the elbows resting on the knees
2. Standing and leaning against the wall
3. Lying on the back in low Fowler’s position
4. Sitting up and leaning on a table
41. The client is about to undergo a lumbar
puncture. The nurse describes to the client that
which of the following positions will be used duringthe procedure?
1. Side-lying with the legs pulled up and the head
bent down onto the chest
2. Side-lying with a pillow under the hip
3. prone with a pillow under the abdomen
4. Prone in slight trendelenburg’s position
42. The nurse recognizes that which of the following
interventions is unlikely to facilitate effective
communication between the dying client and his orher family?
1. The nurse encourages the client and family to
identify and discuss feelings openly.
2. The nurse makes decisions for the client and
family to relieve them of unnecessary demands.
3. The nurse assists the client and family in
carrying out spiritually meaningful practices.
4. The nurse maintains a calm attitude and one of
acceptance when the family or client expresses
anger.
43. The client with acute pancreatitis is experiencing
severe pain from the disorder. The nurse determines
that the client understood suggestions for
positioning to reduce pain if the client avoided.
1. Leaning forward.
2. Drawing the legs up to the chest.
3. Sitting up.
4. Lying flat.
44. The client has had surgery to repair a fractured
left hip. The nurse obtains which of the following
most important items from the unit storage area to
use when repositioning the client from side in bed?
1. Abductor’s splint
2. Adductor splint
3. Bed pillow
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4. Overhead trapeze
45. The nurse is preparing to care for a client who
has undergone a myelogram using a oil-based
contrast agent. The nurse plans to position the clienton bedrest for
1. 6 to 8 hours with the head of bed flat.
2. 6 to 8 hours with the head of bed elevated 15
to degrees.
3. 2 to 4 hours with the head of bed flat.
4. 2 to 4 hours with the head of bed elevated 15
to 30 degrees.
46. The nurse has given activity guidelines to the
client with chronic back pain. The nurse determinesthat the client understood the instructions if the
client states to avoid which of the following
positions?
1. Lying on the side with knees and hips bent
2. Lying prone
3. Standing with one foot on a step or stool
4. Sitting using a lumbar roll or pillow.
47. The nurse has just admitted to the nursing unit a
client with basilar skull fracture who is at risk forincreased intracranial pressure. Pending specific
physician orders, the nurse would avoid placing the
client in which of the following positions?
1. Neck in neutral position
2. Head of bed elevated 30 to 40 degrees
3. Flat with head turned to the side
4. Head midline
48. The nurse reviews the arterial blood gas results
of an assigned client and notes that the laboratoryreport indicates a pH of 7.30, PCO2 of 58 mm Hg, PO2
of 80 mm Hg, and a HCO3 of 27 mEq/L. The nurse
interprets that the client has which acid-base
disturbance?
1. Metabolic Acidosis
2. Metabolic Alkalosis
3. Respiratory Acidosis
4. Respiratory Alkalosis
49. Cortesone acetate (Cortone) is prescribed for a
client with adrenal insufficiency. The nurse provides
instructions to the client regarding the medication.Which statement if made by the client indicates a
need for further instruction?
1. “I will eat a good breakfast every day.”
2. “I will avoid people with colds.”
3. “I will limit my sodium intake.”
4. “I will stop the medication when I feel better.”
50. The hospitalized client with diabetes mellitus
received NPH insulin in the morning. The nurse
monitors the client for hypoglycemia, knowing thatthe peak action occurs.
1. 2 to 4 hours after administration.
2. 6 to 14 hours after administration.
3. 14 to 18 hours after administration.
4. 18 to 24 hours after administration.
51. The nurse has admitted a client to the clinical
nursing unit following modified right radical
mastectomy for the treatment of breast cancer. The
nurse plans to place the right arm in which of thefollowing positions?
1. Elevated above shoulder level
2. Elevated on a pillow
3. Level with the right atrium
4. Dependent to the right atrium.
52. On the second postpartum day, a woman
complains of burning on urination, urgency, and
frequency of urination. A urinalysis is collected, and
the results indicate the presence of a urinary tractinfection. The nurse instruct the new mother
regarding measures to take for the treatment of the
infection. Which of the following statements if made
by the mother would indicate a need for further
instructions?
1. “The prescribed medication must be taken
until it is completed.”
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2. “My fluid intake should be increased to at least
three thousand milliliters daily.”
3. “I need to urinate frequently throughout the
day.”
4. “I should consume foods and fluids that will
increase urine alkalinity.”
53. The registered nurse is beginning a new job in a
clinic and is attending an orientation session.
Following the orientation session, another new
employee asks the registered nurse to describe case
management, a component of the discussion in the
orientation session, because the employee did not
understand the concept clearly. The registered nurse
responds that
1. “Case management requires an experiencednurse because it represents a primary health
prevention focus and is managed by a single nurse.”
2. “Case management saves money for the
institution because client’s with similar problems are
treated in the same manner.”
3. “Case management is an important concept,
but it doesn’t promote appropriate use of
personnel.”
4. “Case management will maximize hospital
revenues and at the same time provide optimal
outcome of client care.”
54. The nurse provides dietary instructions to a
client with diabetes mellitus regarding the
prescribed diabetic diet. Which statement if made by
the client indicates a need for further teaching?
1. “I need to drink diet soft drinks.”
2. “I’ll eat a balanced meal plan.”
3. “I need to purchase special dietetic foods.”
4. “I’ll snack on fruit instead of cake.”
55. The client received 20 units of NPH insulin
subcutaneously at 8 AM. The nurse should assess the
client for a hypoglycemic reaction at
1. 10 AM
2. 11 AM
3. 5 PM
4. 11 PM
56. The community health nurse is working with
disaster relief in a local community following a
hurricane that ruined many homes in thecommunity. The nurse is working to find housing for
the survivors and is organizing counseling services.
These actions of the nurse represents which type of
level of prevention?
1. The primary level of prevention
2. The secondary level of prevention
3. The tertiary level of prevention
4. The fourth level of prevention
57. A pregnant women in her second trimester callsthe prenatal clinic nurse to report a recent exposure
to a child with rubella. Which of the following
responses by the nurse would be most appropriate
and supportive to the woman?
1. “There is no need to be concerned if you don’t
have a fever or rash within the next two days.”
2. “Be sure to tell the doctor on your next
prenatal visit, but there is little risk in the second
trimester.”
3. “You should avoid all school-aged children
during pregnancy.” 4. “You were wise to call. I will check your rubella
titer screening results, and we can identify
immediately whether future interventions are
needed.”
58. The breast-feeding mother of an infant with
lactose intolerance asks the nurse about dietary
measures. The nurse tells the mother to avoid
1. Hard cheeses
2. Green, leafy vegetables3. Dried beans
4. Egg yolk
59. A client with diabetes mellitus is told that
amputation of the leg is necessary to sustain life. The
client is upset and states to the nurse, “This is all the
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doctor’s fault! I have done everything that the
doctors has asked me to do!” The nurse interprets
the clients statements as
1. An expected coping mechanism.
2. A need to notify the hospital lawyer.
3. An expression of guilt on the part of the client.4. An ineffective coping mechanism.
60. A client brought to the emergency room is dead
on arrival. The family of the client tells the physician
that the client had a terminal cancer. The emergency
room physician examines the client and asks the
nurse to contact the medical examiner regarding an
autopsy. The family of the client tells the nurse that
they do not want an autopsy performed. Which of
the following responses to the family is mostappropriate?
1. “It is required by federal law. Why don’t we talk
about it, and why don’t you tell me why you don’t
want the autopsy done?”
2. “The decision is made by the medical
examiner.”
3. “I will contact the medical examiner regarding
your request.”
4. “An autopsy is mandatory for any client who is
dead on arrival.”
61. A pregnant women who is positive for human
immunodeficiency virus (HIV) delivers a newborn
infant, and the nurse provides instruction to help the
mother regarding the newborn infant care. Which
statement by the client indicates the need for
further instructions?
1. “I will be sure to wash my hands before and
following bathroom use.”
2. “Support groups are available to assist me with
understanding my diagnosis of HIV.” 3. “I need to breast-feed, especially for the first
six weeks post-partum.”
4. “My newborn infant should be on antiviral
medication for the first six weeks after delivery.”
62. A pregnant women has a positive history of
genital herpes but has not had lesions during this
pregnancy. The nurse should plan to provide which
of the following information to the client?
1. “You will be isolated from your newborn infant
following delivery.” 2. “You will be evaluated at the time of delivery
for herpetic general tract lesions, and if lesions are
present, a cesarean delivery will be needed.”
3. “There is little risk to your newborn infant
during this pregnancy, birth, and following delivery.”
4. “Vaginal deliveries can reduce neonatal
infection risks even if you have an active lesion at
birth.”
63. A 7-year-old child is diagnosed with viralconjunctivitis. Antibiotic eye drops are prescribed for
the child. The mother asks the nurse when the child
can return to school. The most appropriate response
is
1. “The child can return to school immediately.”
2. “The child should be kept home until the
antibiotic eye drops have been administered for
twenty-four hours .”
3. “The child should be kept home until the
antibiotic eye drops have been administered for
seventy-two hours.” 4. “The child cannot return to school until seen by
the physician in one week.”
64. An adolescent is diagnosed with conjunctivitis,
and the nurse provides information to the
adolescent about the use of contact lenses. Which
statement by the client indicates the need for
further information?
1. “My contact lens can be worn if they are
cleaned as directed.” 2. “I should not wear my contact lens.”
3. “New contact lenses should be obtained.”
4. “My old contact lenses should be discarded.”
65. A pregnant client is seen in the health care clinic
and asks the nurse what causes the breasts to
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change in size and appearance during pregnancy.
The nurse plans to base the response on which of
the following?
1. The breasts changes are due to the secretion of
estrogen and progesterone.
2. The breasts become stretched because of theweight gain.
3. The increased metabolic rate causes the
breasts to become larger.
4. Cortisol secreted by the adrenal glands play a
factor in increasing the size and appearance of the
breasts.
66. The nurse is caring for a client receiving bolus
feedings via Levin-type nasogastric tube. As the
nurse is finishing the feeding, the client asks the bedto be positioned flat to sleep. The nurse understands
that the most appropriate position for this client at
this time is which of the following?
1. Head of bed flat with the client in the supine
position for at least 30 minutes
2. Head of bed elevated 30 to 45 degrees with the
client in the right lateral position for 60 minutes
3. Head of bed elevated 45 to 60 degrees with the
client in the supine position for 90 minutes
4. Head of bed in semi-fowlers position with the
client in the left lateral position for 60 minutes
67. Before administering an intermittent tube
feeding through a nasogastric tube, the nurse assess
for gastric residual. The nurse understands that this
procedure is important to
1. Confirm proper nasogastric tube placement.
2. Observe gastric content.
3. Assess fluid and electrolyte status.
4. Evaluate absorption of the last feeding.
68. A 4-year old child is diagnosed with otitis media.
The mother asks the nurse about the causes of this
illness. The nurse responds, knowing that which of
the following is an unassociated risk factors related
to otitis media?
1. Household smoking
2. Bottle-feeding
3. Exposure to other illness in other children
4. A history of Urinary Tract infections.
69. The pediatric nurse assists the physician inperforming a lumbar puncture on a 3-year-old child
with leukemia suspected of having central nervous
system metastasis. The nurse places a child in which
position for this procedure?
1. Prone with the knees flexed to the abdomen
and the head bent with the chin resting on the chest
2. Modified Sims’ position.
3. Lateral recumbent with the knees flexed to the
abdomen and the head bent with the chin resting on
the chest
4. Lithotomy position
70. A client with diabetes mellitus is self-
administering NPH insulin from a vial that is kept at
room temperature. The client asks the nurse about
the length of time an unrefrigerated vial of insulin
will maintain its potency. The most appropriate
response to the client is which of the following?
1. 2 weeks
2. 1 month
3. 2 months4. 6 months
71. The nurse is caring for a client scheduled for
transphenoidal hypophysectomy. The preoperative
teaching instructions would include which most
important statement?
1. “Your hair will need to be shaved.”
2. “Deep breathing and coughing will be needed
after surgery.”
3. “Toothbrushing will not be permitted for atleast two weeks following surgery.”
4. “You will receive spinal anesthesia.”
72. The nurse caring for a client with addison’s
disease would expect to note which of the following
on assessment of the client?
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1. Obesity
2. Edema
3. Hypotension
4. Hirsutism
73. The nurse is conducting a prepared child birth
class and is instructing a birth class pregnant women
about the method of effleurage. The nurse instructs
the women to perform the procedure by
1. Contracting and the consciously relaxing
different muscle groups.
2. Contracting an area of the body such as an arm
or leg and then concentrating on letting tension go
from the rest of the body.
3. Massaging the abdomen during contractions
using both hands in a circular motion.4. Instructing the significant other to stroke or
massage a tightened muscle by the use of touch.
74. During a routine prenatal visit, the client
complains of gums that bleed easily with brushing.
The nurse performs an assessment and then teaches
the client about proper nutrition to minimize this
problem. Which statement if made by the client
indicates an understanding of the proper nutrition to
minimize this problem?1. “I will eat three savings of cracked wheat bread
each day.”
2. “I will eat fresh fruits and vegetables for snacks
and for dessert each day.”
3. “I will drink eight ounces of water with each
meal.”
4. “I will eat two saltine crackers before I get up
each morning.”
75. A 6-year-old child has just been diagnosed withlocalized Hodgkin’s disease, and chemotherapy is
planned to begin immediately. The mother of the
child asks the nurse why radiation therapy was not
prescribed as a part of the treatment. The most
appropriate and supportive response to the mother
is
1. “I’m not sure. I’ll discuss it with the physician.”
2. “The child is too young to have radiation
therapy.
3. “It’s very costly, and chemotherapy works just
as well.”
4. “The physician would prefer that you discuss
treatment options with the oncologist.”
76. A diagnostic work-up is being performed on a 1-
year-old child suspected of having a diagnosis of
neuroblastoma. The nurse reviews the result of the
diagnostic tests and understands that which finding
is related most specifically to this type of humor?
1. Elevated vanillylmandelic acid urinary levels
2. The presence of blast cells in the bone marrow
3. Projectile vomiting occurring most often in the
morning4. Positive Babinski’s sign
77. The nurse is developing a post-operative plan of
care for a 40-year-old male Filipino client scheduled
for an appendectomy. The nurse most appropriately
includes in the plan of care to
1. Inform the client the he will need to ask for
pain medication when needed.
2. Offer pain medication when non verbal signs of
discomfort are identified.3. Offer pain medication regularly as prescribed.
4. Allow the client to maintain control and
request pain medication on his own.
78. The nurse provides instructions regarding home
care to the parents of a 3-year-old child hospitalized
with hemophilia. Which statement if made by a
parent indicates a need for further instructions?
1. “We will supervise the child closely.”
2. “We will pad corners of the furniture.” 3. “We will remove household items that can fall
over easily.”
4. “We will avoid having the child receive
immunizations and cancel scheduled dental
appointments."
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79. The nurse is planning to instruct the Mexican
American client about nutrition and dietary
restrictions. When developing the plan, the nurse is
aware that this ethnic group
1. Enjoys food that lacks color, flavor, and texture.
2. Primary eat raw fish.3. Enjoys eating red meat.
4. Views food as a primary form of socialization.
80. The registered nurse is planning the client
assignments for the day. Which of the following is
the most appropriate assignment for the nursing
assistant?
1. A client with bladder cancer who will be
receiving chemotherapy.
2. A client on bedrest who requires range ofmotion exercise every 4 hours.
3. A new diabetic mellitus client scheduled for
discharge
4. A client scheduled to receive a blood
transfusion
81. Prophylthiouracil (PTU) is prescribed for the
client with hyperthyroidism. The nurse provides
instructions to the client regarding the medication
and informs the client to notify the physician ifwhich of the following signs occur?
1. Drowsiness
2. Sore throat
3. Increased urination
4. Dry mouth
82. A client who has been taking iodine solution
(Lugol’s solution, potassium iodide solution) is
admitted to the emergency room and iodine
overdose is suspected. Gastric lavage is initiated toremove the iodine from the stomach. In addition to
treatment with gastric lavage, the nurse anticipates
that which of the following will be administered?
1. Calcium gluconate
2. Vitamin K
3. Acetylcysteine (Mucomyst)
4. Sodium thiosulfate
83. The nurse is interviewing a 16-year-old client
during her initial prenatal clinic visit. The client is
beginning week18 of her first pregnancy. Which
statements if made by the client indicates animmediate need for further investigation?
1. “I don’t like my face anymore. I always look like
I have been crying.”
2. “I don’t like my breasts anymore. These silver
lines are ugly.”
3. “I don’t like my stomach anymore. That brown
line is disgusting.”
4. “I don’t like my figure anymore. My clothes are
all too tight.”
84. The client seen in the health care clinic has
tested positive for gonorrhea. The nurse anticipates
that which medication will be prescribed for the
client based on this finding?
1. Ceftriaxone (Rocephin)
2. Penicillin G benzathine (Bicillin)
3. Acyclovir (Zovirax)
4. Azithromycin (Zithromax)
85. The client is brought into the emergency room inventricular fibrillation. The advanced cardiac life
support nurse prepares to defibrillate by placing
conductive gel pads on which part of the chest?
1. To the upper and lower half of the sternum
2. To the right of the sternum just below the
clavicle and to the left of the precordium
3. To the right shoulder and in the back of the left
shoulder
4. Parallel between the umbilicus and the right
nipple
86. A rubella vaccine is prescribed to be
administered to a 2-day postpartum client. The
nurse preparing to administer the vaccine develops a
list of the potential risks associated with this vaccine.
The nurse reviews the list with the client and
cautions the client to avoid
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1. Sunlight for 3 days.
2. Scratching the injection site.
3. Pregnancy for 2 to 3 months after the
vaccination.
4. Sexual intercourse for 2 to 3 months after the
vaccination.
87. The client has undergone mastectomy. The nurse
interprets that the client is making the best
adjustment to the loss of the breast if which of the
following behaviors is observed?
1. Participating in the care of the surgical drain
2. Reading postoperative care booklet
3. Refusing to look at the wound
4. Asking for pain medication when needed
88. The client is preparing for discharge from the
hospital after radical vulvectomy. The nurse plan to
teach this client that which of the following activities
is acceptable after discharge because it will not
precipitate complications?
1. Sexual activity
2. Walking
3. Sitting for lengthy periods
4. Driving a car
89. The child with croup is being discharged from the
hospital. The nurse provides instructions to the
mother and advises the mother to bring the child to
the emergency room if the child
1. Appears tired.
2. Takes fluids poorly.
3. Is irritable.
4. Develops stridor.
90. The emergency room nurse is caring for a child
suspected of epiglottitis and has ensured that the
child has a patent airway. The next priority in the
care of this child would be to
1. Prepare the child for a chest radiograph.
2. Assist the physician with intubation.
3. Prepare the child for tracheostomy.
4. Prepare to administer epinephrine.
91. The nurse reviews a plan of care for a client at 37
weeks of gestation who has sickle cell anemia. The
nurse determines that which nursing diagnosis listedon the nursing care plan will received the highest
priority?
1. Activity Intolerance
2. Disturbed Body image
3. At risk for pain
4. Deficient Fluid Volume
92. The mother arrives at the clinic with her 3-year-
old child. The mother tells the nurse that the child
has had a fever and a cough for the past 2 days andthat this morning the child began to wheeze. Viral
pneumonia is diagnosed. Based on the diagnosis, the
nurse anticipates that which of the following will be
a component of the treatment plan?
1. Orally administered antibiotics
2. Hospitalization and intravenously administered
antibiotics
3. Supportive treatment
4. Intravenous fluid administration
93. A mother of a child with cystic fibrosis asks the
clinic nurse about the disease. The nurse tells the
mother that cystic fibrosis is
1. A disease that causes the formation of multiple
cysts in the lungs.
2. A chronic multisystem disorder affecting the
exocrine glands.
3. Transmitted as an autosomal dominant trait
4. A disease that causes dilation of the
passageways of many organs.
94. Minoxidil solution (Rogaine) is prescribed for the
client to treat hair loss. The nurse tell the client that
the usual dosage for this medication is
1. 1 mL applied 6 times daily.
2. 1 mL applied at bedtime.
3. 1 mL applied 2 times a day.
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4. 1 mL applied 4 times a day.
95. Collagenase (Santyl) is prescribed for a client
with a severe burn to the hand. The home care nurse
provides instructions to the client regarding the useof the medication. Which client statement indicates
an accurate understanding of the use of this
medication?
1. “I will apply the ointment once a day and leave
it open to the air.”
2. “I will apply the ointment once a day and cover
it with a sterile dressing.”
3. “I will apply the ointment twice a day and leave
it open to the air.”
4. “I will apply the ointment at bedtime and in the
morning and cover it with a sterile dressing.”
96. The mother of an infant diagnosed with
Hirschsprung’s disease asks the nurse about the
disorder. The nurse tells the mother that this disease
is a
1. Congenital agangliosis or megacolon.
2. Complete small intestinal obstruction.
3. Condition that causes the pyloric valve to
remain open.
4. Severe inflammation of the gastrointestinaltract.
97. The nurse is preparing to care for a newborn
infant who will be returning from surgery with a
colostomy that was created for imperforate anus.
When the newborn infant returns from surgery, the
nurse assesses the stoma and notes that it i s red and
edematous. Which of the following is the most
appropriate nursing intervention?
1. Call the physician. 2. Document the findings.
3. Apply ice immediately.
4. Elevate the buttocks.
98. The nurse is developing a plan of care for a
preterm newborn infant and is addressing measures
to provide skin care. The nurse develops measures
knowing that the preterm newborn infant’s skin
appears
1. Reddened, thin, and gelatinous with decreased
amounts of subcutaneous fat and open posture.
2. Thin and gelatinous with increasedsubcutaneous fat.
3. Thin and gelatinous with increased amounts of
brown fat.
4. With fine downy hair on a thin epidermal and
dermal layer with increased amount of brown fat.
99. The nurse in the labor room is performing an
initial assessment on a newborn infant. On
assessment of the newborn infant’s head, the nurse
notes that the ears are low set. Which of thefollowing nursing actions would be most
appropriate?
1. Cover the ears with gauze pads.
2. Document the findings.
3. Arrange for hearing testing.
4. Notify the physician.
100. The clinic nurse is assessing the status of
jaundice in a child with hepatitis. Which anatomical
area will provide the best data regarding thepresence of jaundice?
1. The nailbeds
2. The skin in the abdominal area
3. The skin in the sacral area
4. The membranes in the ear canal
101. A prenatal client with a history of heart disease
has been instructed on care at home. Which
statement if made by the client would indicate that
the client understands her needs?1. “There is no restriction on people who visit
me.”
2. “I should avoid stressful situations.”
3. “My weight gain is not important.”
4. “I should rest on my right side.”
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102. A prenatal client has acquired the sexual
transmitted infection human papilloma virus. When
planning care, Which of the following interventions
would the nurse anticipate would be prescribed
because of its safety during pregnancy?
1. Cryotherapy2. Use of cytotoxic agents
3. Treatment with imiquimod
4. Treatment with podophyllin
103. The home care nurse is assigned to visit a
Mexican American client to perform an admission
assessment. On initial meeting of the client, The
nurse would
1. Greet the client with a handshake.
2. Avoid touching the client.3. Avoid any affirmative nods during the
conversations with the client.
4. Smile and use humor throughout the entire
admission assessment.
104. Russell’s traction is prescribed for a child with a
lower leg fracture. The mother of a child asks the
nurse about the purpose of the traction. The nurse
explains to the mother that this type of traction
primarily provides1. Reduction or realignment of a fracture site.
2. Keeps the child from moving around in bed.
3. Provides a form of restraint for the child.
4. Will relieve the child’s pain.
105. The home care nurse’s assignment is to visit a
new mother at home 24 to 48 hours after discharge.
Which of the following would the nurse expect to
note in a healthy mother who is breast-feeding her
newborn infant?1. A mother breast-feeding with the infant in a
tummy to tummy position without signs of cracked
nipples; the baby demonstrates bursts of sucking
followed by a pause and swallow.
2. A mother breast-feeding the infant with the
infant’s head turned toward her breast, with the
body flat in her arms; mother with sore nipples and
infant with a suck blister.
3. A mother complaining of breast engorgement
with the infant demonstrating difficulty in latching
onto the breast.
4. A mother with cracked nipples feeding theinfant with a supplemental bottle.
106. The nurse is assigned to care for a client who is
in traction. The nurse prepares a plan of care for the
client and includes which nursing action in the plan?
1. Monitor the weights to be sure that they are
resting on a firm surface.
2. Check the weights to be sure that they are off
of the floor.
3. Make sure that the knots are at the pulleys.4. Make sure the head of the bed is kept at a 45-
to 90- degree angle.
107. A nurse is setting up the physical environment
for an interview with a client and plans to obtain
subjective data regarding the client’s health. Select
all interventions that are appropriate.
___ Set the room temperature at a comfortable
level.
___ Provides seating for the client so that the clientfaces a strong light.
___ Ensures that the distance between the client
and nurse is at least 6 feet.
___ Place a chair for the client across from the
nurse’s desk.
___ Remove distracting objects from the
interviewing area.
___ Ensure comfortable seating at eye level for the
client and nurse.
108. The private duty nurse has been caring for a
terminally ill client whose death is imminent. The
nurse has developed a close relationship with the
family of the client. Which of the following nursing
interventions will the nurse avoid in dealing with the
family during this difficult time?
1. Making the decisions for the family
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2. Encouraging family discussion of concerns
3. Encouraging family requested clergy visits
4. Accepting the family’s expressions of anger
109. The nurse is reviewing the record of a pregnantclient and notes that the physician has documented
the presence of chadwick’s sign. The nurse
understands that the hormone responsible for the
development of this sign is which of the following?
1. Human chorionic gonadotropin
2. Estrogen
3. Progesterone
4. Prolactin
110. The nurse is caring for an older client who hasbeen placed in Buck’s extension traction following a
hip fracture. On assessment of the client the nurse
notes that the client is disoriented. The most
appropriate nursing intervention is to
1. Ask the family to stay with the client.
2. Apply restraints to the client.
3. Ask the laboratory to perform electrolyte
studies.
4. Reorient the client frequently and place a clock
and a calendar in the client’s room.
111. The nurse is preparing a plan of care for the
client in skin traction. The nurse includes in the plan
that a priority intervention is to assess the client
frequently for
1. The presence of bowel sounds.
2. Signs of infection around the pin sites.
3. Signs of skin breakdown.
4. Urinary incontinence.
112. A contraction stress test is scheduled for the
pregnant client, and the client asks the nurse about
the test. The nurse tells the client that
1. Small amounts of oxytocin (Pitocin) are
administered during internal fetal monitor to
stimulate fetal uterine contractions.
2. An external fetal monitor is attached, and the
women ambulates on a treadmill until contractions
begin.
3. The uterus is stimulated to contract by the use
of small amount of oxytocin (pitocin) or by nipple
stimulation.4. Uterine contractions are stimulated by
Leopold’s maneuvers.
113. The mother arrives at a well-baby clinic with her
1-month-old infant. She expresses concerns because
one of the infant’s eyes appears to be crossed. The
most appropriate and supportive response by the
nurse is which of the following?
1. “The infants will probably need surgery.”
2. “This condition is probably permanent.” 3. “It bears watching because the other eye may
do the same thing.”
4. “This is normal in the young infant but should
not be present after about age four months.”
114. The physician prescribes “patching” for a child
with strabismus of the right eye and the nurse
instructs the mother regarding this procedure.
Which of the following will the nurse include in the
instructions?1. Place the patch on the right eye.
2. Place the patch on both eyes.
3. Place the patch on the left eye.
4. Alternate the patch from the right to the left
eye hourly.
115. A nonstress test is performed on a client who is
pregnant, and the result of the test indicate non
reactive findings. The physician prescribed a
contraction stress test. The test is performed, andthe nurse notes that the physician has documented
the results as negative. The nurse interprets this
finding as indicating
1. A high risk for fetal demise.
2. A normal test result.
3. The need for a cesarean delivery.
4. An abnormal test result.
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116. The nurse has developed a plan of care for a
client who is in traction and documents a nursing
diagnosis of Self-Care Deficit. The nurse evaluate the
plan of care and determines that which of thefollowing observations indicates a successful
outcome?
1. The client allows the nurse to complete the
care daily.
2. The client allows the family to assist in the care.
3. The client refuses care.
4. The client assist in self-care as much as
possible.
117. The home care nurse is visiting a client who is ina body cast. The nurse is performing an assessment
and is assessing the psychosocial adjustment of the
client to the cast. The nurse most appropriately
would assess
1. The type of transportation available for follow-
up care
2. The ability to perform activities of daily living.
3. The need for sensory stimulation.
4. The amount of home care support available.
118. The maternity nurse is providing an in-service
educational session to nursing students regarding
the process of conception. The nurse instruct the
nursing students that fertilization of a mature ovum
occurs in which of the following areas?
1. Uterus
2. Ovary
3. Distal third of the fallopian tube
4. Wall of the myometrium
119. The nurse is preparing to teach a client how to
use crutches safely. Before initiating the teaching,
the nurse performs an assessment on the client. The
priority nursing assessment should include which of
the following?
1. The client’s fear related to the use of the
crutches
2. The client’s understanding of the need for
increased mobility
3. The client’s vital signs, muscle strength, and
previous activity level of the client
4. The client’s feelings about the restricted
mobility.
120. The nurse is assessing for Kernig’s sign in a child
with a suspected diagnosis of meningitis. The nurse
performs this test by
1. Bending the head towards the knees and hips
and assessing for pain.
2. Tapping the facial nerve and assessing for
spasm.
3. Compressing the upper arm and assessing for
tetany.
4. Raising the leg with the knee flexed and thenextending the leg at the knee and assessing for pain.
121. The physician has written an order to start
progressive ambulation as tolerated on a
hospitalized client who experiences periods of
confusion because of bedrest and prolonged
confinement to the hospital room. Which nursing
intervention would be most appropriate when
planning to implement the physician’s order and in
addressing the needs of the client?1. Help the client to ambulate in the room for
short distances frequently.
2. Help the client to ambulate to the bedroom in
the client’s room 3 times a day.
3. Progressively increase ambulation in the hall 3
times a day.
4. Assist with range of motion exercises 3 times a
day to increased strength.
122. A client is seen in the health care clinic, and avitamin K deficiency is suspected. On assessment of
the client the nurse would expect to note which of
the following if this vitamin deficiency were present?
1. Client complaints of night blindness
2. Signs of clotting problems
3. Scaly skin
4. Client complaints of skeletal pain
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123. The nurse is caring for a postterm, small-for-
gestational-age newborn infant immediately after
admission to the nursery. The priority nursing action
would be to monitor1. Urinary output.
2. Total bilirubin levels.
3. Blood glucose levels.
4. Hemoglobin and hematocrit levels.
124. The nurse is performing an initial assessment on
a large-for-gestational-age newborn infant. Which
physical assessment technique would the nurse
perform to assess for the evidence of birth trauma?
1. Palpate the clavicles for a fracture2. Auscultate the heart for a cadiac defect.
3. Blanch the skin for evidence of jaundice.
4. Perform the Ortolani maneuver for hip
dislocation.
125. Somatropin (Humatrope), a growth hormone, is
prescribed for a client. The nurse reviews the
assessment data in the client’s health record,
knowing that the medication is contraindicated in
which of the following conditions?1. A child with growth hormone deficiency
2. A child with pituitary dwarfism
3. A 20-year-old with growth failure
4. A child with growth failure
126. The nurse is caring for a client who is receiving
growth hormone replacement therapy. The nurse
monitors the client for which side effect of this
therapy?
1. Hyperglycemia2. Hyperthyroidism
3. Hypoglycemia
4. Hypocalciuria
127. The nurse is assessing a client with a diagnosis
of goiter. Which of the following would the nurse
expect to note during the assessment of the client?
1. Client complaints of slow wound healing
2. Client complaints of chronic fatigue
3. An enlarged thyroid gland4. The presence of heart damage
128. A fasting blood glucose screening is performed
on a pregnant client. The results indicate that the
blood glucose is 140mg/dL. Which of the following
would the nurse anticipate to be prescribed for the
mother?
1. Administration of an oral hypoglycemic agent
2. Administration of NPH insulin daily
3. A 3-hour glucose tolerance test4. A sliding scale regular insulin dose
129. The pregnant client seen in the health care
clinic has tested positive for human
immunodeficiency virus. Base on this information,
the nurse determines that
1. The client has the herpes simplex virus.
2. Human immunodeficiency virus antibodies are
detected on the enzyme-linked immunosorbent
assay.3. The neonate definitely will develop this disease
after birth.
4. This client has contacted an airborne disease.
130. During a wellness fair, an adult client admits to
a nurse of not eating a well-balanced diet. According
to the Food Guide Pyramid, which of the following
instructions would the nurse provide to the client?
1. “Your diet should consist of six to eleven
servings of bread, cereal, pasta, or rice a day.” 2. “Your diet should consist of two to four
servings of vegetables a day.”
3. “Your diet should consist of four to five servings
of milk, yogurt, or cheese a day.”
4. “Your diet should consist of four to six servings
of meat, poultry, fish, dry beans, or nuts a day.”
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131. An 85-year-old client is hospitalized for a right
fractured hip. During the postoperative period, the
client’s appetite is poor and the client refuses to get
out of bed. Which nursing statement would be most
appropriate to make to the client?1. “It is important for you to get out of bed so that
calcium will go back into the bone.”
2. ”We need to increase your calcium intake
because you are spending too much time in bed.”
3. “We need to give you iodine so that it will help
in hemoglobin synthesis.
4. “You need to remember to turn yourself in bed
every two hours to keep from getting so stiff.”
132. Lindane (Kwell) is prescribed for the treatmentof scabies. The nurse reviews the client’s record,
knowing the medication therapy is contraindicated if
the client is
1. A 42-year-old women.
2. An older client.
3. A 6-year-old child.
4. A 52-year-old man with hypertension.
133. A DuoDerm is prescribed for a client with a leg
ulcer. The home health nurse is preparing a plan ofcare for the client and most appropriately
documents to
1. Change the DuoDerm daily.
2. Apply the DuoDerm over a dry sterile dressing.
3. Change the DuoDerm weekly.
4. Apply the DuoDerm over a normal saline-
soaked dressing.
134. A nurse develops a plan of care for a client
being admitted to the hospital with a diagnosis ofcerebral aneurysm who will be placed on aneurysm
precaution. The nurse includes which intervention in
the plan?
1. Provide the client with a low-fiber-diet.
2. Keep the room lights on to ensure client
orientation to the environment.
3. Place the client in a semiprivate room to
provide stimulation.
4. Restrict visitors to close family or significant
others and keep visits short.
135. Glyburide (DiaBeta) 2.5 mg orally daily is
prescribed for a client. The nurse tells the client
1. To take the medication in the morning before
breakfast
2. To expect his skin color to change from pink to
yellow and to expect pale-colored stools.
3. That the medication is used to prevent foot
infections.
4. That if an altered taste sensation occurs, to
contact the physician immediately.
136. A nurse employed on a medical unit in a
hospital receives a telephone call from the admission
office and is told that a client with a diagnosis of
mycoplasmal pneumonia will be admitted to the
nursing unit. The nurse prepares for the admission
and obtains the necessary supplies to place the
client on which type of transmission-based
precaution?
Answer: DROPLET PRECAUTION
137. A nurse manager is providing an educational
session to nursing staff members about the phases
of viral hepatitis. The nurse manager tells the staff
that which clinical manifestation(s) are primarily
characteristic of the preicteric phase?
1. Right upper quadrant pain
2. Fatigue, anorexia, and nausea
3. Jaundice, dark-colored urine, and clay-colored
stools
4. Pruritus
138. The registered nurse is planning assignments
for the clients on a nursing units. The registered
nurse needs to assign four clients and has a
registered nurse, a licensed practical (vocational)
nurse, and two nursing assistants on a nursing team.
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Which of the following clients would the nurse most
appropriately assign the licensed practical
(vocational) nurse?
1. The client who requires a 24-hour urine
collection
2. An older client requiring assistance with a bedbath and frequent ambulation
3. A client on a mechanical ventilator requiring
frequent assessment and suctioning.
4. A client with an abnormal wound requiring
wound irrigations and dressing changes every 3
hours.
139. A nursing instructor asks the nursing student to
describe the definition of a critical path. Which of
the following statements, if made by the student,indicates a need for further understanding regarding
critical paths?
1. “They are developed through the collaborative
efforts of all members of the health care team.”
2. “They provide an effective way to monitor care
and for reducing or controlling the length of hospital
stay for the client.”
3. “They are developed based on appropriate
standards of care.”
4. “They are nursing care plans and use the steps
of the nursing process.”
140. The nurse is caring for an 18-month old child
who has been vomiting. The most appropriate
position for the child during naps and sleep time is
1. Side-lying position.
2. Prone with the face turned to the side.
3. Supine.
4. Prone with the head elevated.
141. The parents of a child with cleft lip are
concerned and ask the nurse when the lip will be
repaired. The nurse supportively tells the parents
that
1. Cleft lip repair usually is performed between 6
months and 2 years of age.
2. Cleft lip repair usually is performed by 6
months of age.
3. Cleft lip repair usually is performed during the
first week of life.
4. Cleft lip cannot be repaired.
142. The nurse is assessing the client for signs of
postpartum depression. Which of the following if
noted in the new mother, would indicate the need
for further assessment related to this form of
depression?
1. The mother is caring for the infant in a loving
manner.
2. The mother constantly complains of tiredness
and fatigue.
3. The mother demonstrates an interest in thesurroundings.
4. The mother looks forward to visits from the
father of the newborn.
143. A postpartum client is attempting to breast-
feed for the first time. The nurse notes that the
client has inverted nipples. What nursing action can
the nurse take to assist the client in breast-feeding
the newborn infant?
1. Provide breast shells and assist the mother withusing a breast pump before each feeding to make
the nipples easier for the newborn infant to grasp.
2. Have the mother grasp the nipples between
the thumb and the forefinger and tug firmly to get
the nipple to protrude.
3. Massage the breast, applying gentle pressure
on the areola.
4. Take a cool shower, allowing the water to run
over the breast because this will discourage the
nipples to protrude.
144. The nurse instructs the client in breast self-
examination. The nurse tells the client to lie down
and to examine the left breast. The nurse instructs
the client that while examining the left breast to
place a pillow.
1. Under the right shoulder.
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2. Under the left shoulder.
3. Under the small of the back.
4. Under the right scapula.
145. The nurse is teaching a breast-self examinationto a client who had a hysterectomy. The most
appropriate instruction regarding when the breast
self-examination should be performed is
1. 7 to 10 days after menses.
2. Just before menses begins.
3. At ovulation time.
4. At a specific day of the month and on that same
day every month thereafter.
146. The nursing instructor asks the nursing studentto describe Montgomery’s tubercles of the breast.
The student indicates an understanding of this
anatomical structure if the student states that the
Montgomery’s tubercles are
1. Sebaceous glands that are located in the
2. Lobes of glandular tissue that secrete milk.
3. Small sacs that contain acinar cells to secrete
milk
4. Ducts containing milk from all areas of the
breast.
147. The 32-year-old female client has a history of
fibrocystic disorder of the breasts. The nurse
interviewing the client asks whether the breast
lumps are more noticeable.
1. In the spring months.
2. In the autumn.
3. After menses.
4. Before menses.
148. A 1-year-old child is diagnosed with
intussusceptions, and the mother of the child asks
the nurse to describe the disorder. The nurse tells
the mother that this disorder is
1. An acute bowel obstruction.
2. A condition when a proximal segment of the
bowel prolapses into a distal segment of the bowel.
3. A condition when a distal segment of the bowel
prolapses into a proximal segment of the bowel.
4. A condition that causes an acute inflammatory
process in the bowel.
149. A 3-year-old child is seen in the health care
clinic, and a diagnosis of encopresis is made. The
nurse reviews the assessment findings expecting to
note documentation of which sign of this disorder?
1. Nausea and Vomiting
2. Diarrhea
3. Evidence of soiled clothing
4. Malaise and anorexia
150. The nurse is teaching the client who hadlaryngectomy for laryngeal cancer how to use an
artificial larynx. The nurse tells the client to
1. Insert the device into the tracheostomy.
2. Hold the device alongside the neck.
3. Hold the device over the upper portion of the
sternum.
4. Swallow air into the esophagus to make
speech.
151. A client is scheduled for a papanicolaou’s smearat the next scheduled clinic visit. The nurse provides
instructions to the client regarding preparation for
this test. The nurse tells the client that
1. The test can be performed during
menstruation.
2. Fluids are restricted on the day of the test.
3. The test is painless.
4. Vaginal douching is required 2 hours before the
test.
152. A nurse witnesses an accident on highway and
stops to provide assistance to the victim. The nurse
notes that the client sustained a head injury and a
compound fracture to the left leg. The nurse
provides the appropriate care before transport of
the victim to the hospital by ambulance. The client
develops a severe bone infection at the site of the
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fracture that requires amputation of the leg and files
suit against the nurse who provided care at the
scene of the accident. Which of the following is
accurate regarding the nurses immunity from this
suit?
1. The Good Samaritan law will protect the nurse.2. The Good Samaritan law will not protect the
nurse.
3. The Good Samaritan law will provide immunity
from suit even if the nurse accepted compensation
for the care provided.
4. The Good Samaritan law protects laypersons
and not professional healthcare providers.
153. A client is seen in the clinic for complaints of
thirst, frequent urination, and headaches. Followingdiagnostic studies, diabetes insipidus in diagnosed.
Lypressin (Diapid) is prescribed. The nurse instructs
the client that the medication is prescribed to
1. Relieved the headaches.
2. Increase water reabsorption.
3. Decrease the production of the antidiuretic
hormone.
4. Stimulate the production of aldosterone.
154. Somatrem (Protropin) is prescribed for theclient with pituitary dwarfism. The nurse explains