An obstetrical client decides to have an epidural anesthetic to relieve pain
during labor. Following administration of the anesthesia, the nurse
should
... [Show More] monitor the client for:
❍ A. Seizures
❍ B. Postural hypertension
❍ C. Respiratory depression
❍ D. Hematuria
47. The nurse is assessing the client admitted for possible oral cancer. The
nurse identifies which of the following to be a late-occurring symptom of
oral cancer?
❍ A. Warmth
❍ B. Odor
❍ C. Pain
❍ D. Ulcer with flat edges
48. The nurse understands that the diagnosis of oral cancer is confirmed with:
❍ A. Biopsy
❍ B. Gram Stain
❍ C. Oral culture
❍ D. Oral washings for cytology
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49. The nurse is caring for the patient following removal of a large posterior
oral lesion. The priority nursing measure would be to:
❍ A. Maintain a patent airway
❍ B. Perform meticulous oral care every 2 hours
❍ C. Ensure that the incisional area is kept as dry as possible
❍ D. Assess the client frequently for pain
50. The registered nurse is conducting an in-service for colleagues on the
subject of peptic ulcers. The nurse would be correct in identifying which
of the following as a causative factor?
❍ A. N. gonorrhea
❍ B. H. influenza
❍ C. H. pylori
❍ D. E. coli
51. The patient states, “My stomach hurts about 2 hours after I eat.” Based
upon this information, the nurse suspects the patient likely has a:
❍ A. Gastric ulcer
❍ B. Duodenal ulcer
❍ C. Peptic ulcer
❍ D. Curling’s ulcer
52. The nurse is caring for a patient with suspected diverticulitis. The nurse
would be most prudent in questioning which of the following diagnostic
tests?
❍ A. Abdominal ultrasound
❍ B. Barium enema
❍ C. Complete blood count
❍ D. Computed tomography (CT) scan
53. The nurse is planning care for the patient with celiac disease. In teaching
about the diet, the nurse should instruct the patient to avoid which of the
following for breakfast?
❍ A. Puffed wheat
❍ B. Banana
❍ C. Puffed rice
❍ D. Cornflakes
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54. The nurse is teaching about irritable bowel syndrome (IBS). Which of the
following would be most important?
❍ A. Reinforcing the need for a balanced diet
❍ B. Encouraging the client to drink 16 ounces of fluid with
each meal
❍ C. Telling the client to eat a diet low in fiber
❍ D. Instructing the client to limit his intake of fruits and
vegetables
55. In planning care for the patient with ulcerative colitis, the nurse identifies
which nursing diagnosis as a priority?
❍ A. Anxiety
❍ B. Impaired skin integrity
❍ C. Fluid volume deficit
❍ D. Nutrition altered, less than body requirements
56. The patient is prescribed metronidazole (Flagyl) for adjunct treatment for
a duodenal ulcer. When teaching about this medication, the nurse would
include:
❍ A. “This medication should be taken only until you begin to feel
better.”
❍ B. “This medication should be taken on an empty stomach to
increase absorption.”
❍ C. “While taking this medication, you do not have to be concerned about being in the sun.”
❍ D. “While taking this medication, alcoholic beverages and
products containing alcohol should be avoided.”
57. The nurse is preparing to administer a feeding via a nasogastric tube.
The nurse would perform which of the following before initiating the
feeding?
❍ A. Assess for tube placement by aspirating stomach content
❍ B. Place the patient in a left-lying position
❍ C. Administer feeding with 50% Dextrose
❍ D. Ensure that the feeding solution has been warmed in a
microwave for 2 minutes
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58. Which is true regarding the administration of antacids?
❍ A. Antacids should be administered without regard to
mealtimes.
❍ B. Antacids should be administered with each meal and snack
of the day.
❍ C. Antacids should not be administered with other medications.
❍ D. Antacids should be administered with all other medications,
for maximal absorption.
59. The nurse is caring for a patient with a colostomy. The patient asks, “Will
I ever be able to swim again?” The nurse’s best response would be:
❍ A. “Yes, you should be able to swim again, even with the
colostomy.”
❍ B. “You should avoid immersing the colostomy in water.”
❍ C. “No, you should avoid getting the colostomy wet.”
❍ D. “Don’t worry about that. You will be able to live just like you
did before.”
60. The nurse is assisting in the care of a patient who is 2 days post-operative from a hemorroidectomy. The nurse would be correct in instructing
the patient to:
❍ A. Avoid a high-fiber diet
❍ B. Continue to use ice packs
❍ C. Take a laxative daily to prevent constipation
❍ D. Use a sitz bath after each bowel movement
61. The nurse is assisting in the care of a client with diverticulosis. Which of
the following assessment findings must necessitate an immediate report
to the doctor?
❍ A. Bowel sounds are present
❍ B. Intermittent left lower-quadrant pain
❍ C. Constipation alternating with diarrhea
❍ D. Hemoglobin 26% and hematocrit 32
62. The client is newly diagnosed with juvenile onset diabetes. Which of the
following nursing diagnoses is a priority?
❍ A. Anxiety
❍ B. Pain
❍ C. Knowledge deficit
❍ D. Altered thought process
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63. The nurse is asked by the nurse aide, “Are peptic ulcers really caused by
stress?” The nurse would be correct in replying with the following:
❍ A. “Peptic ulcers result from overeating fatty foods.”
❍ B. “Peptic ulcers are always caused from exposure to continual
stress.”
❍ C. “Peptic ulcers are like all other ulcers, which all result
from stress.”
❍ D. “Peptic ulcers are associated with H. pylori, although there
are other ulcers that are associated with stress.”
64. The nurse is assisting in the assessment of the patient admitted with
“extreme abdominal pain.” The nurse asks the client about the medication that he has been taking because:
❍ A. Interactions between medications will cause abdominal pain.
❍ B. Various medications taken by mouth can affect the
alimentary tract.
❍ C. This will provide an opportunity to educate the patient
regarding the medications used.
❍ D. The types of medications might be attributable to an abdominal pathology not already identified.
65. The nurse is assessing the abdomen. The nurse knows the best
sequence to perform the assessment is:
❍ A. Inspection, auscultation, palpation
❍ B. Auscultation, palpation, inspection
❍ C. Palpation, inspection, auscultation
❍ D. Inspection, palpation, auscultation
66. The nurse is caring for the client who has been in a coma for 2 months.
He has signed a donor card, but the wife is opposed to the idea of organ
donation. How should the nurse handle the topic of organ donation with
the wife?
❍ A. Tell the wife that the hospital will honor her wishes regarding
organ donation, but contact the organ-retrieval staff
❍ B. Tell her that because her husband signed a donor card, the
hospital has the right to take the organs upon the death of
her husband
❍ C. Explain that it is necessary for her to donate her husband’s
organs because he signed the permit
❍ D. Refrain from talking about the subject until after the death of
her husband
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67. The client with cancer refuses to care for herself. Which action by the
nurse would be best?
❍ A. Alternate nurses caring for the client so that the staff will not
get tired of caring for this client
❍ B. Talk to the client and explain the need for self-care
❍ C. Explore the reason for the lack of motivation seen in
the client
❍ D. Talk to the doctor about the client’s lack of motivation
68. The charge nurse is making assignments for the day. After accepting the
assignment to a client with leukemia, the nurse tells the charge nurse
that her child has chickenpox. Which initial action should the charge
nurse take?
❍ A. Change the nurse’s assignment to another client
❍ B. Explain to the nurse that there is no risk to the client
❍ C. Ask the nurse if the chickenpox have scabbed
❍ D. Ask the nurse if she has ever had the chickenpox
69. The nurse is caring for the client with a mastectomy. Which action would
be contraindicated?
❍ A. Taking the blood pressure in the side of the mastectomy
❍ B. Elevating the arm on the side of the mastectomy
❍ C. Positioning the client on the unaffected side
❍ D. Performing a dextrostix on the unaffected side
70. The client has an order for gentamycin to be administered. Which lab
results should be reported to the doctor before beginning the medication?
❍ A. Hematocrit
❍ B. Creatinine
❍ C. White blood cell count
❍ D. Erythrocyte count
71. Which of the following is the best indicator of the diagnosis of HIV?
❍ A. White blood cell count
❍ B. ELISA
❍ C. Western Blot
❍ D. Complete blood count
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72. The client presents to the emergency room with a “bull’s eye” rash. Which
question would be most appropriate for the nurse to ask the client?
❍ A. “Have you found any ticks on your body?”
❍ B. “Have you had any nausea in the last 24 hours?”
❍ C. “Have you been outside the country in the last 6 months?”
❍ D. “Have you had any fever for the past few days?”
73. Which client should be assigned to the nursing assistant?
❍ A. The 18-year-old with a fracture to two cervical vertebrae
❍ B. The infant with meningitis
❍ C. The elderly client with a thyroidectomy 4 days ago
❍ D. The client with a thoracotomy 2 days ago
74. The client presents to the emergency room with a hyphema. Which
action by the nurse would be best?
❍ A. Elevate the head of the bed and apply ice to the eye
❍ B. Place the client in a supine position and apply heat to the knee
❍ C. Insert a Foley catheter and measure the intake and output
❍ D. Perform a vaginal exam and check for a discharge
75. The client has an order for FeSo4 liquid. Which method of administration
would be best?
❍ A. Administer the medication with milk
❍ B. Administer the medication with a meal
❍ C. Administer the medication with orange juice
❍ D. Administer the medication undiluted
76. The client with an ileostomy is being discharged. Which teaching should
be included in the plan of care?
❍ A. Using Karaya powder to seal the bag.
❍ B. Irrigating the ileostomy daily.
❍ C. Using stomahesive as the best skin protector.
❍ D. Using Neosporin ointment to protect the skin.
77. Vitamin K is administered to the newborn shortly after birth for which of
the following reasons?
❍ A. To stop hemorrhage
❍ B. To treat infection
❍ C. To replace electrolytes
❍ D. To facilitate clotting
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78. Before administering Methyltrexate orally to the client with cancer, the
nurse should check the:
❍ A. IV site
❍ B. Electrolytes
❍ C. Blood gases
❍ D. Vital signs
79. The nurse is teaching a group of new graduates about the safety needs
of the client receiving chemotherapy. Before administering chemotherapy, the nurse should:
❍ A. Administer a bolus of IV fluid
❍ B. Administer pain medication
❍ C. Administer an antiemetic
❍ D. Allow the patient a chance to eat
80. The client is admitted to the postpartum unit with an order to continue
the infusion of Pitocin. The nurse is aware that Pitocin is working if the
fundus is:
❍ A. Deviated to the left.
❍ B. Firm and in the midline.
❍ C. Boggy.
❍ D. Two finger breadths below the umbilicus.
81. A 5-year-old is a family contact to the client with tuberculosis. Isoniazid
(INH) has been prescribed for the client. The nurse is aware that the
length of time that the medication will be taken is:
❍ A. 6 months
❍ B. 3 months
❍ C. 1 year
❍ D. 2 years
82. A 4-year-old with cystic fibrosis has a prescription for Viokase pancreatic
enzymes to prevent malabsorption. The correct time to give pancreatic
enzyme is:
❍ A. 1 hour before meals
❍ B. 2 hours after meals
❍ C. With each meal and snack
❍ D. On an empty stomach
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83. A client with osteomylitis has an order for a trough level to be done
because he is taking Gentamycin. When should the nurse call the lab to
obtain the trough level?
❍ A. Before the first dose
❍ B. 30 minutes before the fourth dose
❍ C. 30 minutes after the first dose
❍ D. 30 minutes before the first dose
84. A new diabetic is learning to administer his insulin. He receives 10U of
NPH and 12U of regular insulin each morning. Which of the following
statements reflects understanding of the nurse’s teaching?
❍ A. “When drawing up my insulin, I should draw up the regular
insulin first.”
❍ B. “When drawing up my insulin, I should draw up the NPH
insulin first.”
❍ C. “It doesn’t matter which insulin I draw up first.”
❍ D. “I cannot mix the insulin, so I will need two shots.”
85. The client is scheduled to have an intravenous cholangiogram. Before the
procedure, the nurse should assess the patient for:
❍ A. Shellfish allergies
❍ B. Reactions to blood transfusions
❍ C. Gallbladder disease
❍ D. Egg allergies
86. Shortly after the client was admitted to the postpartum unit, the nurse
notes heavy lochia rubra with large clots. The nurse should anticipate an
order for:
❍ A. Methergine
❍ B. Stadol
❍ C. Magnesium sulfate
❍ D. Phenergan
87. The client with a recent liver transplant asks the nurse how long he will
have to take an immunosuppressant. Which response would be correct?
❍ A. 1 year
❍ B. 5 years
❍ C. 10 years
❍ D. The rest of his life
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88. The client is admitted from the emergency room with multiple injuries
sustained from an auto accident. His doctor prescribes a histamine
blocker. The nurse is aware that the reason for this order is to:
❍ A. Treat general discomfort
❍ B. Correct electrolyte imbalances
❍ C. Prevent stress ulcers
❍ D. Treat nausea
89. The physician prescribes regular insulin, 5 units subcutaneous. Regular
insulin begins to exert an effect:
❍ A. In 5–10 minutes
❍ B. In 10–20 minutes
❍ C. In 30–60 minutes
❍ D. In 60–120 minutes
90. A 60-year-old diabetic is taking glyburide (Diabeta) 1.25mg daily to treat
Type II diabetes mellitus. Which statement indicates the need for further
teaching?
❍ A. “I will keep candy with me just in case my blood sugar
drops.”
❍ B. “I need to stay out of the sun as much as possible.”
❍ C. “I often skip dinner because I don’t feel hungry.”
❍ D. “I always wear my medical identification.” [Show Less]