1. A health care provider informs a client that a T-tube will be in place after an abdominal cholecystectomy and a choledochostomy. What should the nurse include in the preoperative teaching for this client regarding the primary reason why a T-tube is necessary?
Drains bile from the cystic duct.
Keeps the common bile duct patent.
Prevents abscess formation at the surgical site.
Provides a port for contrast dye in a cholangiogram.
2. In the immediate postoperative period after a gastrectomy, the client’s nasogastric tube is draining a light-red liquid. For how long should the nurse expect this type of drainage?
1 to 2 hours
3 to 4 hours
10 to 12 hours
24 to 48 hours
3. A nurse is caring for a client who is scheduled for a gastric bypass to treat morbid obesity. Which diet should the nurse teach the client to maintain because it will help minimize clinical manifestations of dumping syndrome?
Low-residue, bland diet
Small, frequent feeding schedule
Fluid intake less than half a quart
Low-protein, high-carbohydrate diet
4. An external monitor is placed on the abdomen of a client admitted in active labor. The nurse identifies that during each contraction, the fetal heart rate decelerates as the contraction peaks. What should the nurse do next?
Help the client to a knee-chest position to avoid cord compression.
Notify the health care provider because of possible head compression.
Monitor the fetal heart rate until it returns to baseline when the contraction ends.
Place the client in a semi-Fowler position to prevent compression of the vena cava.
5. A client who has had thoracic surgery is admitted to the postanesthesia care unit (PACU). What should the nurse do after the chest tube is attached to a disposable plastic waterseal drainage system?
Ensure the security of the connections from the client to the drainage unit.
Empty the drainage container and measure and record the amount once a day.
Verify that there is vigorous bubbling in the wet suction control compartment.
Check that the fluid level in the water seal compartment increases with expiration.
6. An infant is diagnosed with hydrocephalus. Which assessment alerts the nurse to suspect increasing intracranial pressure?
Sunken eyes
Projectile vomiting
Depressed fontanels
Narrowing pulse pressure
7. A client with schizophrenia, paranoid type, is readmitted involuntarily to the hospital because family members state that he has threatened to harm them physically. When exploring feelings about the readmission, the client angrily shouts, “You’re one of them. Leave me alone!” How should the nurse respond?
“Try not to be afraid. I will not hurt you.”
“I can see you are upset. We can talk more later.”
“I am not one of them, and I am here to help you.”
“Your family and the staff are trying to help you.”
8. An older adult is hospitalized for weight loss and dehydration because of nutritional deficits. What should the nurse consider when caring for this client?
Financial resources usually are unrelated to nutritional status.
An older adult’s daily fluid intake must be markedly increased.
The client’s diet should be high in carbohydrates and low in proteins.
The nutritional needs of an older adult are unchanged except for a decreased need for calories.
9. A nurse is assessing a client 8 hours after the creation of a colostomy. Which assessment finding should the nurse expect?
Presence of hyperactive bowel sounds
Absence of drainage from the colostomy
Dusky-colored, edematous-appearing stoma
Red bloody drainage from the nasogastric tube
10. During the first prenatal visit of a woman who is at 23 weeks’ gestation, the nurse discovers that the client has a history of pica. What is the most appropriate nursing action?
Seek a psychologic referral.
Explain the danger this poses to the fetus.
Obtain a prescription for an iron supplement.
Determine whether the diet is nutritionally adequate.
11. An infant with hydrocephalus has a ventriculoperitoneal (VP) shunt surgically inserted. What nursing care is essential during the first 24 hours after this procedure?
Medicating the infant for pain
Placing the infant in a high-Fowler position
Positioning the infant on the side that has the shunt
Monitoring the infant for increasing intracranial pressure
12. A client rescued from a burning building has partial- and full-thickness burns over 40% of the body. Which is the initial physiologic change that the nurse can expect?
An increase in blood volume
An increase in serum potassium
A decrease in capillary permeability
A decrease in urinary specific gravity
13. Methylphenidate (Ritalin) has been prescribed for a 7-year-old child with attention deficit/hyperactivity disorder (ADHD) to be taken with meals. What rationale should the nurse provide for the parents about the timing of medication administration?
Ritalin depresses the appetite.
This will ensure proper absorption.
It is an oral mucous membrane irritant.
Children tend to forget to take it before meals.
14. Shortly after giving birth, a client says she feels that she is bleeding. When checking the fundus, a nurse observes a steady trickling of blood from the vagina. What is the nurse’s initial action?
Call the health care provider.
Check the blood pressure and pulse.
Hold the fundus firmly and gently massage it.
Explain that the trickling blood is a common occurrence.
15. A client with acute respiratory distress syndrome is intubated and placed on a ventilator. What should the nurse do when caring for this client and the mechanical ventilator?
Regulate the PEEP according to the rate and depth of the client’s respirations.
Deflate the cuff on the endotracheal tube for a few minutes every one to two hours.
Assess the need for suctioning when the high-pressure alarm of the ventilator is activated.
Adjust the temperature of fluid in the humidification chamber, depending on the volume of gas delivered.
16. During a group therapy session, some members accuse a client of intellectualizing to avoid discussing feelings. The client asks whether the nurse agrees with the others. What is the nurse’s best response?
“It seems that way to me, too.”
“What is your perception of my behavior?”
“Are you uncomfortable with what you were told?”
“I’d rather not give my personal opinion at this time.”
17. During a routine prenatal visit, a client tells a nurse that she gets leg cramps. What condition does the nurse suspect and what suggestion is made to correct it?
Hypercalcemia and tells her to avoid eating hard cheeses
Hypocalcemia and tells her to increase her intake of milk
Hyperkalemia and tells her to consult with her health care provider
Hypokalemia and tells her to increase her intake of green, leafy vegetables
18. While the nurse is talking to a hypermanic client, the client’s conversation becomes vulgar. How should the nurse respond to the client’s behavior?
Tactfully teasing the client about the use of such vulgarity
Restricting the client’s contact with staff members until the behavior stops
Asking the client to limit the use of vulgarity while continuing the conversation
Discreetly refusing to talk to the client when the client is speaking in this manner
19. A client with schizophrenia has been experiencing hallucinations. During what client behaviors should the nurse expect the hallucinations to be more frequent?
Trying to rest
Playing sports
Watching television
Interacting with others
20. A nurse is caring for a newly admitted client who has been diagnosed with bipolar disorder and has a history of hyperactivity and combativeness. Later in the evening, a commotion is heard, and this client is found hitting another client. What are the legal implications of this situation?
The client should have been placed in restraints on admission.
A client who is known to have been combative should have been kept sedated.
A client with bipolar disorder who is in contact with reality does not require supervision.
Because it was known that the client was frequently combative, close observation by the nursing staff was indicated.
21. A nurse plans care for a client with a somatoform disorder based on the understanding that it is:
a physiologic response to stress.
a conscious defense against anxiety.
an intentional attempt to gain attention.
an unconscious means of reducing stress.
22. What response should a nurse be particularly alert for when assessing a client for side effects of long-term cortisone therapy?
Hypoglycemia
Severe anorexia
Behavioral changes
Anaphylactic shock
23. During the postpartum period a nurse identifies that a client’s rubella titer is negative. What action should the nurse plan to take?
Check for allergies to penicillin.
Alert the staff in the newborn nursery.
Assure the client that she has active immunity.
Obtain a prescription for an immunization before discharge.
24. A nurse observes that an infant has head control and can roll over but can neither sit up without support nor transfer an object from one hand to the other. What developmental age should the nurse estimate based on these observations?
1 to 2 months
3 to 4 months
5 to 6 months
8 to 9 months
25. A health care provider prescribes losartan (Cozaar) for a client. Which is the most important nursing action?
Assess the client for hypokalemia.
Ensure that the medication is ingested with food.
Monitor the client’s blood pressure during therapy.
Teach that a missed dose can be doubled at the next scheduled time.
26. A health care provider orders peak and trough levels of an antibiotic for a client who is receiving vancomycin IV piggyback (IVPB). When should a blood sample be obtained to determine a peak level of the antibiotic?
Anytime it is convenient for the client
Between 30 and 60 minutes after a dose
Halfway between two doses of the drug
At 30 minutes before the medication is administered
27. A nurse is caring for a client with Addison disease. What should the nurse teach the client to do regarding an appropriate diet?
Add extra salt to food.
Limit intake to 1200 calories.
Omit protein foods at each meal.
Restrict the daily intake of fluids to 1 liter.
28. A nurse is teaching sterile technique to a family member of a client who is to be discharged with a large abdominal wound that requires a dressing change twice a day. What does the family member do during a return demonstration that indicates further teaching is necessary?
Sets the sterile field on the client’s linens at the foot of the bed.
Touches the outer inch of the sterile field when placing it on a flat surface.
Checks expiration dates on the sterile packages before donning sterile gloves.
Picks up wet gauze with sterile plastic forceps, holding the tips lower than the wrist.
29. What is important nursing care for children with leukemia on chemotherapeutic protocols?
Preventing physical activity
Checking their vital signs every two hours
Having them avoid contact with infected persons
Reducing unnecessary stimuli in their environment
30. During a prenatal visit, a client at 36 weeks’ gestation tells a nurse that she has painful, irregular contractions. What should the nurse recommend?
Lie down until they stop.
Time them for at least 1 hour.
Walk around until they subside.
Take 1 over-the-counter analgesic.
31. A client is receiving vinCRIStine. What should the nurse expect the dietary plan to include to minimize the side effects of vinCRIStine?
Low in fat
High in iron
High in fluids
Low in residue
32. A client who had an organ transplant is receiving cycloSPORINE (Gengraf). For what should the nurse monitor to identify a serious adverse effect of cycloSPORINE?
Skin for hirsutism
Stools for constipation
Heart rhythm for dysrhythmias
Creatinine level for an increase
33. A nurse is teaching a 10-year-old child with type 1 diabetes about insulin requirements. When should the nurse explain that insulin needs will decrease?
Puberty is reached.
Infection is present
Emotional stress occurs
Active exercise is performed.
34. A nurse identifies that an older adult has not achieved the desired outcome from a prescribed proprietary medication. When assessing the situation, the client shares that the medication is too expensive and the prescription was never filled. What should the nurse do?
Ask the pharmacist to provide a generic form of the drug.
Encourage the client to acquire the medication over the Internet.
Inform the health care provider of the inability to afford the medication.
Suggest that the client purchase insurance that covers prescription drugs.
35. The parents of a newborn who is receiving phototherapy ask a nurse why their baby’s eyes are covered with eye patches. What information should the nurse consider before responding?
They keep the eyes closed.
Overstimulation from bright lights is reduced.
They prevent injury to the conjunctiva and retina.
Excessive rapid eye movements and anxiety are limited.
36. A nurse is teaching a client who has arthritis about the steroid medication prescribed by the health care provider. Which client statement about why it is important to take steroid medication at mealtimes indicates that the teaching was effective?
“The presence of food will enhance the medication’s absorption.
“Taking it with meals serves as a reminder to take the medication.”
“Food will help decrease the gastric irritation effect of the medication.”
“The acid medium in the presence of food makes the medication more effective.”
37. A health care provider prescribes milrinone (Primacor) for a client with a diagnosis of congestive heart failure who was unresponsive to conventional drug therapy. What is most important for the nurse to do first?
Administer the loading dose over ten minutes.
Monitor the ECG continuously for dysrhythmias during infusion
Assess the heart rate and blood pressure continuously during infusion
Have the order, dosage calculations, and pump settings checked by a second nurse.
38. A client is admitted to the postanesthesia care unit after an abdominal hysterectomy. Which assessment should the nurse report to the health care provider immediately?
Apical pulse of 90
Decreased urinary output
Increased drainage from the nasogastric tube
Serosanguineous drainage on the perineal pad 1 hour after surgery
39. A nurse is caring for a child with a very low platelet count related to chemotherapy. The nurse should monitor this child’s urine for the presence of which constituent?
Protein
Glucose
Erythrocytes
Lymphocytes
40. Which complication is avoided when a nurse administers a parenteral preparation of potassium slowly and cautiously?
Acidosis
Cardiac arrest
Psychotic-like reactions
Edema of the extremities
41. The parents of a child with leukemia ask the nurse why irradiation of the spine and skull is necessary. What is the most accurate response by the nurse?
“Radiation retards growth of cells in bone marrow of the cranium.”
“Leukemic cells may invade the nervous system, but the usual drugs are ineffective in the brain.”
“Neoplastic drug therapy without radiation is effective in most cases, but this is a precautionary treatment.”
42. A postoperative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis?
Productive cough
Clubbing of the fingertips
Crackles at the height of inhalation
Diminished breath sounds on auscultation
43. On which concern should the nurse focus when caring for a client after abdominal surgery?
Identifying signs of bleeding
Preventing pressure on the suture site
Encouraging use of an incentive spirometer
Detecting clinical manifestations of inflammation
44. A client is admitted with a diagnosis of chronic adrenal insufficiency. When assigning a room, which roommate should be avoided because of the newly admitted client’s condition?
Young adult client with pneumonia
Adolescent client with a fractured leg
Middle-age client who has cholecystitis
Older adult client who has had a brain attack
45. When admitting a client who is in labor to the birthing unit, a nurse asks the client about her marital status. The client refuses to answer and becomes very agitated, telling the nurse to leave. How should the nurse respond?
Question the family about the clients marital status.
Try to obtain this information to complete the clients history.
Refer the client to the social service department for counseling.
Ask questions that are restricted to the clients present clinical situation.
46. A health care provider prescribes simvastatin (Zocor) 20 mg daily for elevated cholesterol and triglyceride levels for a middle-age female. Which is most important for the nurse to teach the client to do when initially taking this medication?
Take the medication with breakfast.
Have liver function tests twice a year.
Wear sunscreen to prevent photosensitivity reactions.
Inform the health care provider if becoming pregnant is desired.
47. What is the priority nursing intervention on admission of a primigravida in labor?
Monitoring the fetal heart rate
Asking the client when she ate last
Obtaining the client’s health history
Determining if the membranes have ruptured
48. A nurse is caring for a client in the evening after the client has had a below-the-knee amputation. What action should be implemented by the nurse?
Elevate the foot of the bed.
Assist the client out of bed to a chair.
Have the client crutch walk in the room.
Reapply the elastic bandage every two hours.
49. While on a hike, a rusty nail pierces the sole of an adolescent’s foot and the adolescent is brought to the emergency department of a local hospital. Tetanus immune globulin is prescribed because the adolescent does not know when the last tetanus immunization was received. The nurse administers the prescribed dose of tetanus immune globulin and explains that it provides:
lifelong passive immunity.
long-lasting active protection.
immediate passive short-term immunity.
stimulation for the production of antibodies.
50. A nurse is caring for a client with the diagnosis of bulimia nervosa. The nurse understands that individuals with bulimia use food to: