KAPLAN DIAG A MS3
1. The nurse cares for the client diagnosed as being in the manic phase of bipolar disorder. Which behavior indicates
to the nurse the
... [Show More] client condition is improving?
a. The client offers suggestions to other clients on the unit
b. The client begins to write a book about life
c. The client sits and eats with other clients on unit
d. The client talks with other clients a group meeting
2. The health care provider orders a continuous intravenous aminophylline infusion for a two year old client. It is most
important for the nurse to intervene for which situation?
a. The client heart rate is 100 bpm
b. The clients blood pressure is 100/60 mmHg
c. The clients serum theophylline level is 25 mcg/mL
d. The client is sleepy
3. The nurse teaches the client about the schedule cardiac catheterization. Which statement, if made by the client to the
nurse, indicates that the teaching was effective?
a. "I understand that there is little or no risk associated with this procedure."
b. "I may experience a little pounding sensation in my chest during the procedure."
c. "I will be in and out of the procedure room in about 30 minutes."
d. "I will be able to walk in the hall soon after the procedure is completed."
4. During the second stage of labor, the client's partner asks the nurse, "Can I go get a cup of coffee from the
cafeteria?" Which response by the nurse is best?
a. "I will get you a cup of coffee."
b. "It would be best if you stayed here at this time."
c. "Ask your partner if it is acceptable to leave."
d. "Why do you want to leave the room?"
5. The nurse discovers that client lying face down on the floor. Which action does the nurse take first?
a. Assess the patency of the client's airway
b. Determine whether the client is responsive
c. Check the client's carotid pulse
d. Reposition the client onto the back
6. A nurse works 3 weeks at a 100-bed suburban hospital after working several months at a 40-bed rural hospital. The
nurse prefers the total client care delivery system that was used at the rural hospital, rather then the team leading
system of client care that is used at the suburban hospital. Which action does the nurse take?
a. Works with in the system at the hospital to change the type of client care delivery
b. Discuss his thoughts about the type of client care delivery system with the nurses supervisor
c. Asks the nurses peers why this type of client care delivery system is used
d. Suggests a change in the type of client care delivery system to the director of nursing
7. The nurse cares for the client diagnosed with a left traumatic below knee amputation (BKA) with a tourniquet
in place. The client also has a tear from the perineum to the rectum. Which action is the nurse take first?
a. Apply anti-shock trousers
b. Assesses the clients level of consciousness
c. Remove the tourniquet
d. Check the client's blood pressure and pulse
8. During morning rounds, the client diagnosed with schizophrenia tells the nurse, "I know you are conspiring with
my spouse to keep me locked away." Which statement by the nurse is the most appropriate?
a. "What makes you think your spouse is trying to hide your existence?"
b. "Are you saying that you think your spouse doesn't love you?"
c. "I can see that you are frightened about being here but I am a nurse in a hospital."
d. "I'm not conspiring with your spouse. I first met your spouse when you are admitted to the hospital."
9. During a routine prenatal visit, the nurse auscultates the fetal heart rate (FHR). If the fetal position is left
sacrum posterior (LSP), at which site does the nurse expect to find the fetal heart (FHT)?
a. Below umbilicus, on the mothers right
b. Below umbilicus, on the mothers left c.
Above umbilicus, on the mothers left
d. Above umbilicus, on the mothers right
10. The nurse makes environmental rounds on the client care unit. Which problem does the nurse addressed first?
a. A wheel of the medication cart is broken
b. The needle disposal unit in unoccupied room is full
c. The call light and occupied isolation room is
broken
d. The ice machine and the visitors lounge is leaking water on the floor
11. The nurse observes a nursing assistive personnel (NAP) enter the room of the client diagnosed with tuberculosis
(TB) to provide morning care. Which observation, if you made by the nurse, does not require an intervention?
a. The NAP enters the room while wearing goggles and a hair covering
b. That NAP enters the room while wearing a mask and sterile gloves
c. The NAP enters the room while wearing a gown and clean gloves
d. The NAP enters the room while wearing a particulate respirator and a gown
12. The nurse teaches the client about ferrous sulfate. Which statement by the client indicates to the nurse that the
client understands the education?
a. "I should take this medication when I take my antacid."
b. "I should take this medication with orange juice."
c. "I should increase my intake of foods that contain calcium."
d. "I should take this medication at bedtime."
13. The nurse gives discharge instructions about home care for orchitis to the client. Which statement indicates to the
nurse that teaching has been successful?
a. "I should make an appointment to have a circumcision."
b. "It will help if I use a scrotal support."
c. "I should restrict my athletic activities for about 6 weeks."
d. "I need to stay in bed for at least 10 days."
14. The nurse cares for the client having a left total hip arthroplasty period in which position does the nurse placed
the client after surgery?
a. Legs abducted with the toes pointing upward
b. Legs adducted with a bed cradle in place
c. Flat on the bed with a foot board in place
d. Legs elevated on two pillows with the knees flexed
15. The adolescent receives 10 units of intermediate-acting insulin every morning at 0700. If the client requires the
insulin dosage reduced, the nurse expects the client to present with which symptom?
a. Declines lunch at 1200
b. Reports hunger at 0900
c. Experiences confusion at 1600
d. Becomes sleepy at 2100
16. The nurse discovers the client in the bathroom attempting self-harm. Which action does the nurse take first?
a. Removes the client from the bathroom and escorts the client to the bedroom
b. Stays with the client and continually monitors for self-destructive behaviors
c. Initiates a discussion with the client concerning reasons for self-harm
d. Distracts the client from trying to hurt self by talking about the family.
17. The nurse admits a 2-month-old infant for surgical correction of hypospadias. Which assessment does the nurse
complete?
a. Check this scrotal sac and palpate the testes
b. Inspect the position of the urinary meatus
c. Obtained a urine sample for analysis
d. Measure intake and output hourly
18. The patient of an 18 month old toddler ask the nurse, (Which toy is most appropriate for my child?) The nurse
from recommend which toy?
a. A story book
b. A stuffed animal
c. A colorful mobile
d. A large yo-yo
19. The nurse cares for the client prior to cataract surgery. The nurse administers the preoperative medication. Ten
minutes later, the nurse finds the client on the floor at the foot of the bed. Which action does the nurse takes
initially?
a. a. Notifies the healthcare provider, and receive new orders
b. b. Complete accident report documenting the fall
c. c. Stays with the client and calls for assistance
d. d. Moves the client back onto the bed providing support to the cervical area
20. The nurse teaches the client what to expect during a cardiac catheterization. Which statement if made by the client,
indicates further teaching is necessary?
a. "I may feel a fluttering sensation in my chest during the test."
b. "I may kill chest pain during the test."
c. "I may have chest pain for several days following the test."
d. "I may have some pain at the catheter insertion site."
21. The parents of the 18 month old toddler with a fractured femur visits with the child in the hospital. The parents
say they must go home, the child screams, cries, and hits the parents. Which statement does the nurse suggest the
parents tell the child?
a. "We will return in a little while."
b. "We will come back at 1000 hours."
c. "We will return when the sun comes up."
d. "We will come back as soon as we can."
22. The nurse supervises a nursing assistive personnel (NAP) caring for the client after abdominal surgery.
Which observation requires an intervention by the nurse?
a. a. The NAP massages the client's leg using long, firm strokes
b. b. The NAP massages the client arms using smooth, gentle strokes
c. c. The NAP assist the client to put the joints through range of motion exercises
d. d. The NAP positions the client side-lying and applies lotion to the back
23. The nurse cares for the client diagnosed with anorexia nervosa. Which goal is the highest priority initially?
a. Stabilize the clients weight
b. Encourage the client to gain insight about body image
c. Maintain the clients fluid and electrolyte balance
d. Increase the clients caloric intake
24. The nurse administers medications to the client diagnosed with bipolar disorder. The client approaches the nurse and
begins to throw things. Which action does the nurse take?
a. Get another nurse to assist with the client
b. Give the client the medications, so the client will calm down
c. Admonishes the client, and suggested the client collect self
d. Sits down and asks the client what is bothering the client
25. The nurse prepares to assess the blood pressure of the six year old child following an accident. A blood pressure
cuff of appropriate size is unavailable. Which action does the nurse take?
a. Uses another site appropriate for the size of the bailable cost to obtaining reading
b. Wait until proper equipment is available before proceeding to check the blood pressure
c. Use a smaller blood pressure cuff and checked to reading in both arms
d. Uses a larger cost, and add 10 mm Hg to the systolic reading
26. The healthcare provider orders tobramycin for a 3-year-old child. The nurse enters the clients room to administer the
medication and discovers that the child does not have an identification bracelet. Which action by the nurse is the
most appropriate?
a. Ask a coworker to identify the child before giving the medication
b. Ask the parents at the child's bedside to state their child's name
c. Hold the medication until an identification bracelet can be obtained from the admitting office
d. Ask the child to save the child's first and last name
27. The nurse changes the dressing on a client two days after a bowel resection. After opening a sterile pack and putting
on the sterile gloves at the clients bedside, the nurse notes the dressing needed for the dressing change are missing.
Which action does the nurse take next?
a. Remove the gloves, obtained the missing dressings, and replaces the clubs to continue with the procedure
b. Closes the pack, obtained the missing dressing and new gloves, and reopen the pack to continue with
procedure
c. Presses the call light, ask the nurse assistive personnel to bring the missing dressings to the clients room,
and then continues with the procedure
d. Remains in place at the clients bedside while the nursing assistive personnel obtains the missing dressings,
and then continues with the procedure
28. 29. The client receives parenteral nutrition (PN) via the internal jugular vein. Which action does the nurse take if
the next container of PN solution is not available when it is needed?
a. Slows down the PN infusion until the new solution is available
b. Hangs a container of 0.9% NaCl until the new solution is
available c. Hangs a container of 10% D/W until the new solution
is available
d. Uses a heparin lock until the new solution is available
29. The nurse cares for the client with a history of chronic alcohol abuse, nutritional problems, and confabulation.
In planning for the clients nursing care, which action is the first priority of the nurse?
a. Restrict visitors to minimize environmental stimuli
b. Provide a high-calorie, high- protein diet as ordered
c. Start a intravenous line of D5W with thiamine as ordered
d. Monitor behaviors for documentation of confabulation
30. The nurse cares for the school- aged Child diagnosed with cystic fibrosis (CF). The healthcare provider orders
aerosol therapy. The nurse knows which is the expected outcome?
a. The child's appetite improves
b. The child displays no evidence of infection
c. The child manages respiratory secretions without difficulty
d. The child's activity level increases
31. Which situation suggests a nurse is addicted to the use of alcohol or habit-forming medications?
a. The nurse questions a client's medication order left by a healthcare provider
b. The nurse volunteers to "Float" to another unit at the hospital
c. The nurse cannot be found on the unit for half an hour during the assigned shift
d. The nurse questions a client about paying before administering a narcotic analgesic
32. The nurse assesses the intravenous (IV) site on the left forearm of the child. Which finding causes the nurse
to rule out the occurrence of infiltration of the IV?
a. The fluid in that IV tubing becomes pink tinged when the tubing is pinched
b. The end of the needle can be palpated in the vein in the left forearm
c. The amount of fluid infused through the IV site is a half- hour behind schedule
d. The skin on the left arm distal to the IV insertion site is cool and dry
33. The nurse cares for the client diagnosed with a left tibia fracture. The client has a long - leg walking cast
applied. Several hours later, the client states, "I can't feel my toes." It is most important for the nurse to take a
which action?
a. Ask the client to wiggle the toes
b. Observe the foot for edema
c. Assess the clients femoral pulse
d. Check the skin temperature of the foot
34. The charge nurse notes that during a staff meeting designed to discuss client care concerns, a nurse that is a nonnative
speaker of English remains silent. Which action does the charge nurse take?
a. Require all the nurses at the meeting to verbalize their thoughts about the topic under discussion
b. Allow extra time during the meeting for questions and summarize the discussion of the group
c. Take the none-native nurse a side after the meeting and restate the major conclusions of the discussion
d. Check with the non-native nurse before the conclusion of the discussion to see if the discussion topics were
understood
35. The nurse cares for the client with a chest tube attach to a three-chamber water sealed drainage system. While
attempting to get out of bed, the client accidentally disconnect the chest tube from the water-seal drainage system.
Which action does the nurse take first?
a. Inserts the end of the chest tube in a container of sterile saline solution
b. Clamps the chest tube near the water- seal drainage system
c. Applies a dressing to the chest tube insertion site
d. Obtains a new water- seal drainage system
36. The nurse teaches the client, scheduled for a total right hip arthroplasty, preoperatively. Teaching includes
postoperative exercises. Which exercise, if perform by the client, indicates further teaching is necessary?
a. The client performs straight leg lifts
b. The client performs plantar and dorsiflexion exercises
c. The client demonstrates quadriceps and gluteal setting
d. The client demonstrate active range of motion exercises of the ankle
37. The nurse cares for the client receiving peritoneal dialysis. Which finding, if observed by the nurse during
the procedure, indicate a malfunction in the system?
a. There is a leak of fluid onto the dressing in the bed
b. The client reports rectal pain on infusion of the dialysate
c. More dialysate is returned then was infused
d. The clients blood pressure decreases
38. The client scheduled for a vaginal hysterectomy tells the nurse, "I want to read my medical record." Which action
does the nurse take?
a. Asks the clients health care provider if the client can read the medical record.
b. Relays the clients request to read medical medical record to the nurses supervisor
c. Gives the medical record to the client, and remains with the client while the client reads it
d. Tells the client the medical record is the property of the hospital
39. The nurse cares for a client diagnosed with primary adrenocorticol insufficiency. The nurse expects to observe
which laboratory finding?
a. Decreased sodium and glucose; increased potassium
b. Decrease sodium and potassium; increased glucose
c. Increased sodium and potassium; decreased glucose
d. Increased sodium and glucose; decreased potassium
40. The nurse works with the client who has a history of alcoholism. Which statement, if made by the client to the nurse,
indicates that the client has gained some insight into alcoholism?
a. "I know I can stop drinking if I put my mind to it."
b. "For the sake of my family, I will never drink again."
c. "I know this is a lifelong problem, and I'll need continued support."
d. "I know that Alcoholics Anonymous (AA) is available in case the problem gets worse."
41. The parent arrives from overseas to visit. The child discovers the parent depressed, disheveled, and suspicious of
family members. The nurse include which nursing order in the care plan?
a. Encourage family involvement in clients treatment.
b. Involve the local international community and the clients care
c. Set limits on family visits until the client is stable
d. Assign the client to structured group activity
42. The home health nurse changes dressings four times a week for the client diagnosed with stage III pressure
ulcer. The hospital admitting nurse notes that the dressing was not applied as ordered. Which action is most
important for the nurse to take?
a. Contact the nursing supervisor in the hospital to report the discrepancy
b. Contact the home health nurse who has been caring for the client to report the discrepancy
c. Contact the home health supervisor to report the discrepancy
d. Document the discrepancy between what was ordered and the condition of the dressing
43. The nurse gives a client morphine 10mg intramuscularly (IM). After administering the medication, the nurse notes
the order for morphine was deleted by the healthcare provider the previous day and replaced with an order of
hydromorphone 4mg IM. Which documentation is best?
a. "Morphine 10mg given IM into left ventrogluteal area for report of a domino pain. Healthcare provider
notified."
b. "Morphine 10 mg given IM for reports the pain. Hydromorphone 4 mg IM ordered. Incident report
completed."
c. "Morphine 10 mg given IM for reports of abdominal pain instead of hydromorphone 4mg IM.
Incident reported to healthcare provider."
d. "Morphine given for report of incisional pain. Vital signs unchanged. Client resting resting comfortably.
States pain is relieved."
44. 45. The spouse of the 60 - year - old client brings the client to the clinic. The spouse states that during the last
week the client has become confused and has been drinking large quantities of water. Lab values indicate: blood
glucose 1,215 mg/dL (67.43 mmol/L), see osomolality 400 mOsmol/kg H2O (400 mmol/kg H2O), potassium 4.5 mEq/L
(4.5 mmol/L), sodium 145 mEq/L (145 mmol/L), and serum negative for ketones. The nurse expects the healthcare
provider to initially order which treatment?
a. 0.45% NaCl IV and isophane insulin IV
b. D5 0.9% NaCl IV and isophane insulin SQ
c. D5W IV and regular insulin SQ
d. 0.9% NaCl IV and regular insulin IV
45. The parents bring their 9-month-old child to the clinic. Which observation by the nurse indicates a delay
in development?
a. The child begins to cry when the nurse approaches
b. The child can sit unsupported
c. The child uses a Palmer grasp to hold objects
d. The child can clap the hand when asked to do so
46. An hour and a half after admission to the nursery, the nurse observe spontaneous jerky movements of the lambs
and infant born to a mother with just station on diabetes mellitus (GDM). Based on these signs, which condition
does the nurse expect in the infant?
a. Hyperbilirubinemia
b. Cold stress
c.
Hypoglycemi
a
d. Neurological impairment
47. The nurse cares for the client with an above-knee (AKA) amputation performed four days ago. The nurse teaches
the client about care of the residual limb prior to being fitted with a temporary prosthesis. Which intervention is most
important for the nurse to include an instruction?
a. Expose the residual limb to air 30 minutes daily
b. Elevate the residual limb on pillows at night
c. Wrap the residual limb with an elastic bandage during the day
d. Inspect the residual limb daily
48. To ensure a safe hospital environment for a 2-year-old toddler, which intervention does the nurse implement?
a. Arranges for one of the parents to stay with the client
b. Pads the rails of the clients crib
c. Places the client and they use bed
d. Remove equipment from the bedside table
49. The nurse cares for the client diagnosed with a loss of ability to use language following a stroke. Which action
does the nurse take?
a. Involve the family members as translators
b. Utilize both verbal and nonverbal communication
c. Write out all information on an erasable board
d. Focus efforts on reducing the clients frustration when communicating
50. The nurse assesses the client who has a chest tube and a three-chamber water-seal drainage system connected
dissection. Which occurrence requires an intervention by the nurse?
a. The collection container contains 100 mL of serosanguineous fluid
b. There is continuous bubbling in the section control chamber c.
There is continuous bubbling in the water-seal chamber
d. The fluid in the chest tube fluctuates with the clients respirations
51. The clients adult children bring their 70-year-old parent, in the early stages of Alzheimer's disease, to the
medical clinic. Which symptom does the nurse expect the client to exhibit?
a. The client walks with a slow, staggering gate
b. The client cannot remember what the client had for breakfast that morning
c. The client reports generalized body aches
d. The client cannot remember the clients children's names
52. The nurse takes care of the client admitted to rule out epilepsy. Which action is the highest priority for the nurse?
a. Protect the client from injury
b. Accurately document any seizures the client might have
c. Monitor the client from medication side effects
d. Provide for client assessment and teaching
53. The nurse observes cardiopulmonary resuscitation (CPR) Being performed on an 8-months-old client. The
nurse intervenes if which observation is made by the nurse?
a. The client's nose and mouth are covered by the rescuers mouth
b. The clients neck is hyperextended
c. The depth of chest compressions is about 1 1/2 inches deep
d. The rate of chest compressions is 100 per minute
54. The client at 32 weeks gestation visits the healthcare provider. While the nurse palpates the woman's abdomen, the
woman suddenly says, "I feel dizzy. I feel as if I'm going to faint." The nurse identifies which condition causes
the clients response?
a. Maternal anxiety causing peripheral vasoconstriction
b. Postural hypotension resulting from a change of position
c. Inappropriate Leopold's maneuvers compressing blood flow to the fetus
d. Hypotensive syndrome causing a reduction in cardiac output
55. The nurse teaches the client newly diagnosed with type I diabetes. Which statement by the nurse best explains the
rationale for rotating injection sites for this client?
a. "You may damage the tissues causing erratic absorption of insulin if you don't rotate sites."
b. "You may develop an infection if you use the same area too frequently
c. "You may damage to the superficial nerves in the skin and lose sensation if you use the same area to
frequently."
d. "your thighs will eventually becomes sore if you don't change injection sites."
56. The nurse performs a venipuncture using an intravenous (IV) catheter for a client scheduled for surgery.
Which technique does the nurse use?
a. Pierces the skin and the vein in one swift motion
b. Inserts the catheter through the skin and the 30° angle
c. Releases the tourniquet after cleaning the skin alcohol
d. Insert the catheter through the skin with the devil down
57. The nurse cares for the adolescent scheduled for surgery to repair extensive facial scarring sustained any motor
vehicle accident. The nurse assesses the clients understanding of the operation. Which response, if made by the client
to the nurse, indicated the client has the capacity for abstract thinking?
a. "When I was in the hospital right after the accident, the nurse who took care of me showed me what the
skin graft with look like on a doll."
b. "The first thing I am going to do when I finish with this operation is begin saving for my own car."
c. "I'm scared that my face will look worse after the surgery than it does now. This operation sounds horrible."
d. d. "The healthcare provider talked to me about the different techniques involved and the risk of the skin
graft being rejected."
58. The new patient holds the two week old neonate E erect with the feet touching the table top. The baby responds by
flexing and extending the legs. The parent says to the nurse, "look my baby is trying to walk!" Which response, if
made by the nurse to the parent, is best? [Show Less]