1. The nurse is caring for a client scheduled for removal of a pituitary tumor using the
transsphenoidal approach. The nurse should be particularly alert... [Show More] for:
A. Nasal congestion
B. Abdominal tenderness
C. Muscle tetany
D. Oliguria
Answer A: Removal of the pituitary gland is usually done by a transsphenoidal approach,
through the nose. Nasal congestion further interferes with the airway. Answers B, C, and D are
not correct because they are not directly associated with the pituitary gland.
2. A client with cancer is admitted to the oncology unit. Stat lab values reveal Hgb 12.6,
WBC 6500, K+ 1.9, uric acid 7.0, Na+ 136, and platelets 178,000. The nurse evaluates that the
client is experiencing which of the following?
A. Hypernatremia
B. Hypokalemia
C. Myelosuppression
D. Leukocytosis
Answer B: Hypokalemia is evident from the lab values listed. The other laboratory findings are
within normal limits, making answers A, C, and D
incorrect.
3. A 24-year-old female client is scheduled for surgery in the morning. Which of the
following is the primary responsibility of the nurse?
A. Taking the vital signs
B. Obtaining the permit
C. Explaining the procedure
D. Checking the lab work
Answer A: The primary responsibility of the nurse is to take the vital signs before any surgery.
The actions in answers B, C, and D are the responsibility of the doctor and, therefore, are
incorrect for this question.
4. The nurse is working in the emergency room when a client arrives with severe burns of
the left arm, hands, face, and neck. Which action should receive priority?
A. Starting an IV
B. Applying oxygen
C. Obtaining blood gases
D. Medicating the client for pain
Answer B: The client with burns to the neck needs airway assessment and supplemental oxygen,
so applying oxygen is the priority. The next action should be to start an IV and medicate for pain,
making answers A and C incorrect. Answer D, obtaining blood gases, is ordered by the doctor.
5. The nurse is visiting a home health client with osteoporosis. The client has a new
prescription for alendronate (Fosamax). Which instruction should be given to the client?
A. Rest in bed after taking the medication for at least 30 minutes
B. Avoid rapid movements after taking the medication
C. Take the medication with water only
D. Allow at least 1 hour between taking the medicine and taking other medications
Answer B: The client with burns to the neck needs airway assessment and supplemental oxygen,
so applying oxygen is the priority. The next action should be to start an IV and medicate for pain,
making answers A and C incorrect. Answer D, obtaining blood gases, is ordered by the doctor.
6. The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs.
Which equipment should be kept at the bedside?
A. A pair of forceps
B. A torque wrench
C. A pair of wire cutters
D. A screwdriver
Answer B: A torque wrench is kept at the bedside to tighten and loosen the screws of crutchfield
tongs. This wrench controls the amount of pressure that is placed on the screws. A pair of
forceps, wire cutters, and a screwdriver, in answers A, C, and D, would not be used and, thus, are
incorrect.
7. An infant weighs 7 pounds at birth. The expected weight by 1 year should
be:
A. 10 pounds
B. 12 pounds
C. 18 pounds
D. 21 pounds
Answer D: A birth weight of 7 pounds would indicate 21 pounds in 1 year, or triple his birth
weight. Answers A, B, and C therefore are incorrect.
8. A client is admitted with a Ewing’s sarcoma. Which symptoms would be expected due to
this tumor’s location?
A. Hemiplegia
B. Aphasia
C. Nausea
D. Bone pain
Answer D: Sarcoma is a type of bone cancer; therefore, bone pain would be expected. Answers
A, B, and C are not specific to this type of cancer and are incorrect.
9. The nurse is caring for a client with epilepsy who is being treated with carbamazepine
(Tegretol). Which laboratory value might indicate a serious side effect of this drug?
A. Uric acid of 5mg/dL
B. Hematocrit of 33%
C. WBC 2,000 per cubic millimeter
D. Platelets 150,000 per cubic millimeter
Answer C: Tegretol can suppress the bone marrow and decrease the white blood cell count; thus,
a lab value of WBC 2,000 per cubic millimeter indicates side effects of the drug. Answers A and
D are within normal limits, and answer B is a lower limit of normal; therefore, answers A, B, and
D are incorrect.
10. A 6-month-old client is admitted with possible intussuception. Which question during the
nursing history is least helpful in obtaining information regarding this diagnosis?
A. “Tell me about his pain.”
B. “What does his vomit look like?”
C. “Describe his usual diet.”
D. “Have you noticed changes in his abdominal size?”
Answer C: The least-helpful questions are those describing his usual diet. A, B, and D are useful
in determining the extent of disease process and, thus, are incorrect.
11. The nurse is assisting a client with diverticulosis to select appropriate foods. Which food
should be avoided?
A. Bran
B. Fresh peaches
C. Cucumber salad
D. Yeast rolls
Answer C: The client with diverticulitis should avoid foods with seeds. The foods in answers A,
B, and D are allowed; in fact, bran cereal and fruit will help prevent constipation.
12. A client has rectal cancer and is scheduled for an abdominal perineal resection. What
should be the priority nursing care during the post-op period?
A. Teaching how to irrigate the illeostomy
B. Stopping electrolyte loss in the incisional area
C. Encouraging a high-fiber diet
D. Facilitating perineal wound drainage
Answer D: The client with a perineal resection will have a perineal incision. Drains will be used
to facilitate wound drainage. This will help prevent infection of the surgical site. The client will
not have an illeostomy, as in answer A; he will have some electrolyte loss, but treatment is not
focused on preventing the loss, so answer B is incorrect. A high-fiber diet, in answer C, is not
ordered at this time.
13. The nurse is performing discharge teaching on a client with diverticulitis who has been
placed on a low-roughage diet. Which food would have to be eliminated from this client’s diet?
A. Roasted chicken
B. Noodles
C. Cooked broccoli
D. Custard
Answer C: The client with diverticulitis should avoid eating foods that are
gas forming and that increase abdominal discomfort, such as cooked broccoli. Foods such as
those listed in answers A, B, and D are allowed.
14. The nurse is caring for a new mother. The mother asks why her baby has lost weight
since he was born. The best explanation of the weight loss is:
A. The baby is dehydrated due to polyuria.
B. The baby is hypoglycemic due to lack of glucose.
C. The baby is allergic to the formula the mother is giving him.
D. The baby can lose up to 10% of weight due to meconium stool, loss of extracellular fluid,
and initiation of breast-feeding.
Answer D: After birth, meconium stool, loss of extracellular fluid, and initiation of breastfeeding
cause the infant to lose body mass. There is no evidence to indicate dehydration, hypoglycemia,
or allergy to the infant formula; thus, answers A, B, and C are incorrect.
15. The nurse is caring for a client with laryngeal cancer. Which finding ascertained in the
health history would not be common for this diagnosis?
A. Foul breath
B. Dysphagia
C. Diarrhea
D. Chronic hiccups
Answer C: Diarrhea is not common in clients with mouth and throat cancer. All the findings in
answers A, B, and D are expected findings. [Show Less]
