1) The LPN/LVN receives the client's next scheduled bag of TPN labeled with the
additive NPH insulin. Which action should the nurse implement?
A.Hang
... [Show More] the solution at the current rate.
B.Refrigerate the solution until needed.
C.Prepare the solution with new tubing.
D.Return the solution to the pharmacy.
2) A male client has just undergone a laryngectomy and has a cuffed tracheostomy
tube in place. When initiating bolus tube feedings postoperatively, when should the
nurse inflate the cuff?
A.Immediately after feeding
B.Just prior to tube feeding
C.Continuous inflation is required
D.Inflation is not required
3) A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid
ventricular response. Based on this finding, the nurse anticipates assisting the
physician with which treatment?
A.Administer lidocaine,75 mg intravenous push.
B.Perform synchronized cardioversion.
C.Defibrillate the client as soon as possible.
D.Administer atropine, 0.4 mg intravenous push.
4) A 63-year-old client with type 2 diabetes mellitus is admitted for treatment of an
ulcer on the heel of the left foot that has not healed with wound care. The nurse
observes that the entire left foot is darker in color than the right foot. Which
additional symptom should the nurse expect to find?
A.Pedal pulses will be weak or absent in the left foot.
B.The client will state that the left foot is usually warm.
C. Flexion and extension of the left foot will be limited.
D.Capillary refill of the client's left toes will be brisk.
5) A client with cirrhosis develops increasing pedal edema and ascites. Which
dietary modification is most important for the nurse to teach this client?
A.Avoid high-carbohydrate foods.
B.Decrease intake of fat-soluble vitamins.
C.Decrease caloric intake.
D.Restrict salt and fluid intake.
6) During report, the nurse learns that a client with tumor lysis syndrome is
receiving an IV infusion containing insulin. Which assessment should the nurse
complete first?
A.Review the client's history for diabetes mellitus.
B.Observe the extremity distal to the IV site.
C.Monitor the client's serum potassium and blood glucose levels.
D.Evaluate the client's oxygen saturation and breath sounds.
7) A resident in a long-term care facility is diagnosed with hepatitis B. Which
intervention should the nurse implement with the staff caring for this client?
A.Determine if all employees have had the hepatitis B vaccine series.
B.Explain that this type of hepatitis can be transmitted when feeding the client.
C.Assure the employees that they cannot contract hepatitis B when providing
direct care.
D.Tell the employees that wearing gloves and a gown are required when providing
care.
8) The LPN/LVN notes that the client's drainage has decreased from 50 to 5 mL/hr
12 hours after chest tube insertion for hemothorax. What is the best initial action
for the nurse to take?
A.Document this expected decrease in drainage.
B.Clamp the chest tube while assessing for air leaks.
C.Milk the tube to remove any excessive blood clot buildup.
D.Assess for kinks or dependent loops in the tubing.
9) The nurse notes that a client who is scheduled for surgery the next morning has
an elevated blood urea nitrogen (BUN) level. Which condition is most likely to
have contributed to this finding?
A.Myocardial infarction 2 months ago
B.Anorexia and vomiting for the past 2 days
C.Recently diagnosed type 2 diabetes mellitus
D.Skeletal traction for a right hip fracture
10) The nurse is reviewing routine medications taken by a client with chronic angle
closure glaucoma. Which medication prescription should the nurse question?
A.Antianginal with a therapeutic effect of vasodilation
B.Anticholinergic with a side effect of pupillary dilation
C.Antihistamine with a side effect of sedation
D.Corticosteroid with a side effect of hyperglycemia
11) A 58-year-old client who has no health problems asks the nurse about
receiving the pneumococcal vaccine (Pneumovax). Which statement given by the
nurse would offer the client accurate information about this vaccine?
A.The vaccine is given annually before the flu season to those older than 50 years.
B.The immunization is administered once to older adults or those at risk for illness.
C.The vaccine is for all ages and is given primarily to those persons traveling
overseas to areas of infection.
D. The vaccine will prevent the occurrence of pneumococcal pneumonia for up to 5
years.
12) The nurse is assessing a male client with acute pancreatitis. Which finding
requires the MOST immediate intervention by the nurse?
A.The client's amylase level is three times higher than the normal level.
B.While the nurse is taking the client's blood pressure, he has a carpal spasm.
C.On a 1 to 10 scale, the client tells the nurse that his epigastric pain is at 7.
D.The client states that he will continue to drink alcohol after going home.
13) During assessment of a client in the intensive care unit, the nurse notes
that the client's ARE CLEAR UPON AUSCULTATION, but jugular vein
distention and muffled heart sounds are present. Which intervention should the
nurse implement?
A.Prepare the client for a pericardial tap.
B.Administer intravenous furosemide (Lasix).
C.Assist the client to cough and breathe deeply.
D.Instruct the client to restrict the oral fluid intake.
14) After attending a class on reducing cancer risk factors, a client selects bran
flakes with 2% milk and orange slices from a breakfast menu. In evaluating
the client's learning, the nurse affirms that the client has made good choices
and makes what additional recommendation?
A.Switch to skim milk.
B.Switch to orange juice.
C.Add a source of protein.
D.Add herbal tea.
15) A client diagnosed with angina pectoris complains of chest pain while
ambulating in the hallway. Which action should the nurse implement first?
A.Support the client to a sitting position.
B. Ask the client to walk slowly back to the room.
C.Administer a sublingual nitroglycerin tablet.
D.Provide oxygen via nasal cannula.
16) A client is diagnosed with an acute small bowel obstruction. Which
assessment finding requires the most immediate intervention by the nurse?
A.Fever of 102° F
B.Blood pressure of 150/90 mm Hg
C.Abdominal cramping
D.Dry mucous membranes
17) A tornado warning alarm has been activated at the local hospital. Which
action should the charge nurse working on a surgical unit implement first?
A.Instruct the nursing staff to close all window blinds and curtains in clients'
rooms.
B.Move clients and visitors into the hallways and close all doors to clients'
rooms.
C. Visually confirm the location of the tornado by checking the windows on
the unit.
D. Assist all visitors with evacuation down the stairs in a calm and orderly
manner.
18) A client with alcohol-related liver disease is admitted to the unit. Which
prescription should the nurse call the health care provider about for
reverification for this client?
A.Vitamin K1 (AquaMEPHYTON), 5 mg IM daily
B.High-calorie, low-sodium diet
C.Fluid restriction to 1500 mL/day
D.Pentobarbital (Nembutal sodium) at bedtime for rest
19) A female client who received a nephrotoxic drug is admitted with acute
renal failure and asks the nurse if she will need dialysis for the rest of her life.
Which pathophysiologic consequence should the nurse explain that supports
the need for temporary dialysis until acute tubular necrosis subsides?
A.Azotemia
B.Oliguria
C.Hyperkalemia
D.Nephron obstruction
20) Which instruction should the nurse teach a female client about the
prevention of toxic shock syndrome?
A. "Get immunization against human papillomavirus (HPV)."
B. "Change your tampon frequently."
C. "Empty your bladder after intercourse."
D. "Obtain a yearly flu vaccination."
21) A postoperative client receives a Schedule II opioid analgesic for pain.
Which assessment finding requires the most immediate intervention by the
nurse?
A.Hypoactive bowel sounds with abdominal distention
B.Client reports continued pain of 8 on a 10-point scale
C.Respiratory rate of 12 breaths/min, with O2 saturation of 85%
D.Client reports nausea after receiving the medication
22) A client is being discharged following radioactive seed implantation for
prostate cancer. What is the most important information that the nurse should
provide to this client's family?
A.Follow exposure precautions.
B.Encourage regular meals.
C.Collect all urine.
D.Avoid touching the client.
23) An emaciated homeless client presents to the emergency department
complaining of a productive cough, with blood-tinged sputum and night
sweats. Which action is most important for the emergency department triage
nurse to implement for this client?
A.Initiate airborne infection precautions.
B.Place a surgical mask on the client.
C.Don an isolation gown and latex gloves.
D.Start protective (reverse) isolation precautions.
24) Which abnormal laboratory finding indicates that a client with diabetes
needs further evaluation for diabetic nephropathy?
A.Hypokalemia
B.Microalbuminuria
C.Elevated serum lipid levels
D.Ketonuria
25) An older client is admitted with a diagnosis of bacterial pneumonia.
Which symptom should the nurse report to the health care provider after
assessing the client?
A.Leukocytosis and febrile
B.Polycythemia and crackles
C.Pharyngitis and sputum production
D.Confusion and tachycardia
26) Which nursing action is necessary for the client with a flail chest?
A.Withhold prescribed analgesic medications.
B.Percuss the fractured rib area with light taps.
C.Avoid implementing pulmonary suctioning.
D.Encourage coughing and deep breathing.
27) When assigning clients on a medical-surgical floor to an RN and a PN, it
is best for the charge nurse to assign which client to the PN?
A.A young adult with bacterial meningitis with recent seizures
B.An older adult client with pneumonia and viral meningitis
C.A female client in isolation with meningococcal meningitis
D.A male client 1 day postoperative after drainage of a brain abscess
28) When educating a client after a total laryngectomy, which instruction
would be most important for the nurse to include in the discharge teaching?
A.Recommend that the client carry suction equipment at all times.
B.Instruct the client to have writing materials with him at all times.
C.Tell the client to carry a medical alert card that explains his condition.
D.Caution the client not to travel outside the United States alone.
29) A central venous catheter has been inserted via a jugular vein, and a
radiograph has confirmed placement of the catheter. A prescription has been
received for a medication STAT, but IV fluids have not yet been started.
Which action should the nurse take prior to administering the prescribed
medication?
A.Assess for signs of jugular venous distention.
B.Obtain the needed intravenous solution.
C.Flush the line with heparinized solution.
D.Flush the line with normal saline.
30) In caring for a client with acute diverticulitis, which assessment data
warrants immediate nursing intervention?
A.The client has a rigid hard abdomen and elevated WBC.
B.The client has left lower quadrant pain and an elevated temperature.
C.The client is refusing to eat any of the meal and is complaining of nausea.
D.The client has not had a bowel movement in 2 days and has a soft abdomen.
31) The nurse is giving preoperative instructions to a 14-year-old client
scheduled for surgery to correct a spinal curvature. Which statement by the
client best demonstrates that learning has taken place?
A. "I will read all the teaching booklets you gave me before surgery."
B. "I have had surgery before, so I know what to expect afterward."
C. "All the things people have told me will help me take care of my back."
D. "Let me show you the method of turning I will use after surgery."
32) The nurse on a medical surgical unit is receiving a client from the
postanesthesia care unit (PACU) with a Penrose drain. Before choosing a
room for this client, which information is most important for the nurse to
obtain?
A.If suctioning will be needed for drainage of the wound
B.If the family would prefer a private or semiprivate room
C.If the client also has a Hemovac in place
D.If the client's wound is infected
33) The nurse is completing an admission interview for a client with
Parkinson's disease. Which question will provide additional information about
manifestations that the client is likely to experience?
A. "Have you ever experienced any paralysis of your arms or legs?"
B. "Do you have frequent blackout spells?"
C. "Have you ever been frozen in one spot, unable to move?"
D. "Do you have headaches, especially ones with throbbing pain?"
34) A hospitalized client is receiving nasogastric tube feedings via a small bore tube and a continuous pump infusion. He begins to cough and produces a
moderate amount of white sputum. Which action should the nurse take
FIRST?
A.Auscultate the client's breath sounds.
B.Turn off the continuous feeding pump.
C.Check placement of the nasogastric tube.
D.Measure the amount of residual feeding.
Correct Answer: B.Turn off the continuous feeding pump.
35) The nurse is caring for a critically ill client with cirrhosis of the liver who
has a nasogastric tube draining bright red blood. The nurse notes that the
client's serum hemoglobin and hematocrit levels are decreased. Which
additional change in laboratory data should the nurse expect?
A.Increased serum albumin level
B.Decreased serum creatinine
C.Decreased serum ammonia level
D.Increased liver function test results
Correct Answer: C.Decreased serum ammonia level
36) During the shift report, the charge nurse informs a nurse that she has been
assigned to another unit for the day. The nurse begins to sigh deeply and
tosses about her belongings as she prepares to leave, making it known that she
is very unhappy about being floated to the other unit. What is the best
immediate action for the charge nurse to take?
A.Continue with the shift report and talk to the nurse about the incident at a
later time.
B.Ask the nurse to call the house supervisor to see if she must be reassigned.
C.Stop the shift report and remind the nurse that all staff are floated equally.
D.Inform the nurse that her behavior is disruptive to the rest of the staff.
Correct Answer: A.Continue with the shift report and talk to the nurse about the
incident at a later time.
37) The LPN/LVN is administering a nystatin suspension (Mycostatin) for
stomatitis. Which instruction will the nurse provide to the client when
administering this medication?
A. "Hold the medication in your mouth for a few minutes before swallowing
it."
B. "Do not drink or eat milk products for 1 hour prior to taking this
medication."
C. "Dilute the medication with juice to reduce the unpleasant taste and odor."
D. "Take the medication before meals to promote increased absorption."
Correct Answer: "Hold the medication in your mouth for a few minutes before
swallowing it."
38) Which condition should the nurse anticipate as a potential problem in a
female client with a neurogenic bladder?
A.Stress incontinence
B.Infection
C.Painless gross hematuria
D.Peritonitis
Correct Answer: B.Infection
39) A client is ready for discharge following the creation of an ileostomy.
Which instruction should the nurse include in discharge teaching?
A.Replace the stoma appliance every day.
B.Use warm tap water to irrigate the ileostomy.
C.Change the bag when the seal is broken.
D.Measure and record the ileostomy output.
Correct Answer: C.Change the bag when the seal is broken.
40) In assessing a client with an arteriovenous (AV) shunt who is scheduled
for dialysis today, the nurse notes the ABSENCE of a thrill or bruit at the
shunt site. What action should the nurse take?
A.Advise the client that the shunt is intact and ready for dialysis as scheduled.
B.Encourage the client to keep the shunt site elevated above the level of the
heart.
C.Notify the health care provider of the findings immediately.
D.Flush the site at least once with a heparinized saline solution.
Correct Answer: C.Notify the health care provider of the findings immediately.
41) The nurse is preparing a 45-year-old client for discharge from a cancer
center following ileostomy surgery for colon cancer. Which discharge goal
should the nurse include in this client's discharge plan?
A.Reduce the daily intake of animal fat to 10% of the diet within 6 weeks.
B.Exhibit regular, soft-formed stool within 1 month.
C.Demonstrate the irrigation procedure correctly within 1 week.
D.Attend an ostomy support group within 2 weeks.
Correct Answer: D.Attend an ostomy support group within 2 weeks.
42) A client with hypertension has been receiving ramipril (Altace), 5 mg PO,
daily for 2 weeks and is scheduled to receive a dose at 0900. At 0830, the
client's blood pressure is 120/70 mm Hg. Which action should the nurse take?
A.Administer the prescribed dose at the scheduled time.
B.Hold the dose and contact the health care provider.
C.Hold the dose and recheck the blood pressure in 1 hour.
D.Check the health care provider's prescription to clarify dose.
Correct Answer: A.Administer the prescribed dose at the scheduled time.
43) A client with type 2 diabetes takes metformin (Glucophage) daily. The
client is scheduled for major surgery requiring general anesthesia the next day.
The nurse anticipates which approach to manage the client's diabetes best
while the client is NPO during the perioperative period?
A.NPO except for metformin and regular snacks
B.NPO except for oral antidiabetic agent
C.Novolin N insulin subcutaneously twice daily
D.Regular insulin subcutaneously per sliding scale
Correct Answer: D.Regular insulin subcutaneously per sliding scale
44) The nurse is assessing a 75-year-old client for symptoms of
hyperglycemia. Which symptom of hyperglycemia is an OLDER adult most
likely to exhibit?
A.Polyuria
B.Polydipsia
C.Weight loss
D.Infection
Correct Answer: D.Infection
45) The nurse teaches a client with type 2 diabetes nutritional strategies to
decrease obesity. Which food item(s) chosen by the client INDICATES
UNDERSTANDING of the teaching? (Select all that apply.)
A.White bread
B.Salmon
C.Broccoli
D.Whole milk
E.Banana
Correct Answer: B, C, E
B. Salmon
C.Broccoli
E.Banana
46) A practical nurse (PN) tells the charge nurse in a long-term facility that
she does not want to be assigned to one particular resident. She reports that the
male client keeps insisting that she is his daughter and begs her to stay in his
room. What is the best managerial decision?
A. Notify the family that the resident will have to be discharged if his behavior
does not improve.
B. Notify administration of the PN's insubordination and need for counseling
about her statements.
C. Ask the PN what she has done to encourage the resident to believe that she
is his daughter.
D.Reassign the PN until the resident can be assessed more completely for
reality orientation.
Correct Answer: D Reassign the PN until the resident can be assessed more
completely for reality orientation.
47) The nurse is preparing a teaching plan for a group of healthy adults.
Which individual is most likely to maintain optimum health?
A.A teacher whose blood glucose levels average 126 mg/dL daily with oral
anti diabetic drugs
B.An accountant whose blood pressure averages 140/96 mm Hg and who says
he does not have time to exercise
C.A stock broker whose total serum cholesterol level dropped to 290 mg/dL
with diet modifications
D.A recovering IV heroin user who contracted hepatitis more than 10 years
ago
Correct Answer: A.A teacher whose blood glucose levels average 126 mg/dL daily
with oral anti diabetic drugs
48) What is the most important nursing priority for a client who has been
admitted for a possible kidney stone?
A.Reducing dairy products in the diet
B.Straining all urine
C.Measuring intake and output
D.Increasing fluid intake
Correct Answer: B.Straining all urine
49) A client is admitted to the hospital with a diagnosis of severe acute
diverticulitis. Which nursing intervention has the highest priority?
A.Place the client on NPO status.
B.Assess the client's temperature.
C. Obtain a stool specimen.
D.Administer IV fluids.
Correct Answer: A.Place the client on NPO status.
50) The nurse includes frequent oral care in the plan of care for a client
scheduled for an esophagogastrostomy for esophageal cancer. This
intervention is included in the client's plan of care to address which nursing
diagnosis?
A.Fluid volume deficit
B.Self-care deficit
C.Risk for infection
D.Impaired nutrition
Correct Answer: C.Risk for infection
51) A family member was taught to suction a client's tracheostomy prior to the
client's discharge from the hospital. Which observation by the nurse indicates
that the family member is capable of correctly performing the suctioning
technique?
A.Turns on the continuous wall suction to −190 mm Hg
B.Inserts the catheter until resistance or coughing occurs
C.Withdraws the catheter while maintaining suctioning
D.Reclears the tracheostomy after suctioning the mouth
Correct Answer: B.Inserts the catheter until resistance or coughing occurs
52) A client diagnosed with chronic kidney disease (CKD) 2 years ago is
regularly treated at a community hemodialysis facility. Before his scheduled
dialysis treatment, which electrolyte imbalance should the nurse anticipate?
A.Hypophosphatemia
B.Hypocalcemia
C.Hyponatremia
D.Hypokalemia
Correct Answer: B Hypocalcemia
53) As an adolescent is receiving care, he's inadvertently injured with a warm
compress. The nurse completes an incident report based on the knowledge that
identification of which of the following is a goal of the report?
1. To reprimand the involved staff members for their actions
2. To identify the learning needs of staff to prevent incident recurrences
3. To reprimand the nurse-manager responsible for the unit
4. To hold people accountable for their actions
Correct Answer: 2
54) As a client progresses through pregnancy, she develops constipation. What
is the primary cause of this problem during pregnancy?
1. Decreased appetite
2. Inadequate fluid intake
3. Prolonged gastric emptying
4. Reduced intestinal motility
Correct Answer: 4 Reduced intestinal motility
55) An adolescent with type 1 diabetes mellitus is experiencing a growth
spurt. Which treatment approach would be most effective for this client?
1. Administering insulin once per day
2. Administering multiple doses of insulin
3. Limiting dietary fat intake
4. Substituting an oral anti diabetic agent for insulin
Correct Answer: 2. Administering multiple doses of insulin
56) A client is admitted to the health care facility with bowel obstruction
secondary to colon cancer. The nurse obtains a health history, measures vital
signs, and auscultates for bowel sounds. Which step of the nursing process is
the nurse performing?
1. Planning
2. Data collection
3. Evaluation
4. Implementation
Correct Answer: 2. Data collection
57) The physician prescribes meperidine (Demerol), 1.1 mg/kg I.M., for a 16-
month-old child who has just had abdominal surgery. When administering this
drug, the nurse should use a needle of which size?
1. 18G
2. 20G
3. 23G
4. 27G
Correct Answer: 3 23G
58) Which finding in a neonate suggests hypothermia?
1. Bradycardia
2. Hyperglycemia
3. Metabolic alkalosis
4. Shivering
Correct Answer: 1 Bradycardia
59) Initial client assessment information includes blood pressure 160/110 mm
Hg, pulse 88 beats/minute, respiratory rate 22 breaths/minute, and reflexes
+3/+4 with 2 beat clonus. Urine specimen reveals +3 protein, negative sugar
and ketones. Based on these findings, the nurse would expect the client to
have which complaints?
1. Headache, blurred vision, and facial and extremity swelling
2. Abdominal pain, urinary frequency, and pedal edema
3. Diaphoresis, nystagmus, and dizziness
4. Lethargy, chest pain, and shortness of breath
Correct Answer: 1. Headache, blurred vision, and facial and extremity swelling
60) The nurse is performing a baseline assessment of a client's skin integrity.
Which of the following is a key assessment parameter?
1. Family history of pressure ulcers
2. Presence of existing pressure ulcers
3. Potential areas of pressure ulcer development
4. Overall risk of developing pressure ulcers
Correct Answer: 4. Overall risk of developing pressure ulcers
61) The nurse is preparing to boost a client up in bed. She instructs the client
to use the overbed trapeze. Which risk factor for pressure ulcer development is
the nurse reducing by instructing the client to move in this manner?
1. Friction
2. Impaired circulation
3. Localized pressure
4. Shearing forces
Correct Answer: 4. Shearing forces
62) A geriatric client with Alzheimer's disease has been living with his grown
child's family for the last 6 months. He wanders at night and needs help with
activities of daily living. Which statement by his child suggests that the family
is successfully adjusting to this living arrangement?
1. "It's difficult dealing with Dad. It's a thankless job."
2. "We had no idea this would be so difficult. It's our cross to bear."
3. "Dad really seems to be making progress. We're hoping he'll be able to
move back into his house soon."
4. "Dad has presented many challenges. We have alarms on all the outside
doors now. Respite care gives us a break."
Correct Answer: 4 "Dad has presented many challenges. We have alarms on all
the outside doors now. Respite care gives us a break."
63) The nurse is assessing an elderly client. When performing the assessment,
the nurse should consider that one normal age-related change is:
1. cloudy vision.
2. incontinence.
3. diminished reflexes.
4. tremors.
Correct Answer: 3 diminished reflexes.
64) An agitated, confused client arrives in the emergency department. The
client's history includes type 1 diabetes, hypertension, andangina pectoris.
Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat
blood glucose sample measures 42 mg/dl, and the client is treated for an acute
hypoglycemic reaction. After recovery, the nurse teaches the client to treat
hypoglycemiaby ingesting:
1. 2 to 5 g of a simple carbohydrate.
2. 10 to 15 g of a simple carbohydrate.
3. 18 to 20 g of a simple carbohydrate.
4. 25 to 30 g of a simple carbohydrate.
Correct Answer: 2 10 to 15 g of a simple carbohydrate.
65) A 43-year-old man was transferring a load of firewood from his front
driveway to his backyard woodpile at 10 a.m. when he experienced a
heaviness in his chest and dyspnea. He stopped working and rested, and the
pain subsided. At noon, the pain returned. At 1:30 p.m., his wife took him to
the emergency department. Around 2 p.m., the emergency department
physician diagnoses an anterior myocardial infarction (MI). The nurse should
anticipate which immediate order by the physician?
1. Lidocaine administration
2. Cardiac stress test
3. Serial liver enzyme testing
4. Tissue plasminogen activator (tPA)
Correct Answer: 4. Tissue plasminogen activator (tPA) [Show Less]