1. A nurse is caring for a client with a below-the-knee amputation. What should the nurse encourage the client to do to prepare the residual limb for a prosthesis?
Abduct the residual limb when ambulating.
Dangle the residual limb off the bed frequently.
Soak the residual limb in warm water twice a day.
Press the end of the residual limb against a pillow periodically.
2. An IV infusion of magnesium sulfate is prescribed for a client with severe preeclampsia. The dose is twice the usual adult dose. When a nurse questions the dosage, the health care provider insists that it is the desired dose and directs the nurse to administer the medication. How should the nurse respond to this directive?
Administer the dose and monitor the client.
Withhold the dose and notify the nurse manager.
Administer the dose and document it on the client’s record.
Withhold the dose and notify the director of the obstetric department.
3. A client with severe preeclampsia is hospitalized. What should a nurse do first to ensure her physical safety?
Decrease environmental stimuli.
Place her on seizure precautions.
Administer the prescribed sedatives.
Strictly monitor her intake and output.
4. A client is admitted to the hospital with a diagnosis of an exacerbation of asthma. What should the nurse plan to do to best help this client?
Determine the client’s emotional state.
Give prescribed drugs to promote bronchiolar dilation.
Provide education about the impact of a family history.
Encourage the client to use an incentive spirometer routinely.
5. A pregnant adolescent at 10 weeks’ gestation visits the prenatal clinic for the first time. The nutrition interview indicates that her dietary intake consists mainly of soft drinks, candy, French fries, and potato chips. Why does the nurse consider this diet inadequate?
Caloric content will result in too great a weight gain.
Ingredients in soft drinks and candy can be teratogenic in early pregnancy.
Salt in this diet will contribute to the development of gestational hypertension.
Nutritional composition of the diet places her at risk for a low-birth-weight infant.
6. The cervix of a client in labor is dilated 8 cm. She tells a nurse that she has a desire to push and is becoming increasingly uncomfortable. She requests pain medication. How should the nurse respond?
Help her to take panting breaths.
Prepare the birthing bed for the birth.
Assist her out of bed to the bathroom.
Administer the prescribed butorphanol (Stadol).
7. A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD). What complications are most commonly associated with COPD?
Cardiac problems
Joint inflammation
Kidney dysfunction
Peripheral neuropathy
8. During a newborn assessment a nurse reports a sign of respiratory distress. What clinical manifestation did the nurse identify?
Flaring nares
Rapid heart rate
Abdominal respirations
Decreased respiratory rate
9. Which factor is essential to consider when a nurse evaluates whether a unit environment is conducive to psychologic safety for a confused client with dementia?
Needs are met entirely.
Nursing care is flexible.
Realistic limits and controls are set.
Physical surroundings are clean and orderly.
10. A nurse is assessing a group of older adults. Which should the nurse consider to be least likely to be affected by aging?
Sense of taste or smell
Gastrointestinal motility
Muscle or motor strength
Strategies to handle stress
11. What should be the initial nursing action after the birth of a preterm infant with an Apgar score of 6?
Check and clamp the umbilical cord.
Dry the infant and place in a warm environment.
Obtain a footprint and apply an identification band.
Get resuscitative equipment and assist the health care provider.
12. During the first trimester, a client tells a nurse at the prenatal clinic that she frequently feels nauseated. What should the nurse teach her about reducing the nausea?
Eat small, frequent meals.
Take an antacid between meals.
Drink cinnamon tincture before rising.
Take dimenhydrinate (Dramamine) at bedtime.
13. A new parent asks a nurse how to care for the baby’s umbilical cord stump. What should the nurse include in the teaching?
Expect a moderate amount of drainage.
Keep the area moist with sterile normal saline.
Provide sponge baths until the stump falls off.
Cover the site with a small sterile dressing twice a day.
14. After resection of a lower lobe of the lung, a client has excessive respiratory secretions. Which independent nursing action should the nurse implement?
Postural drainage
Turning and positioning
Administration of an expectorant
Percussion and vibration techniques
15. A client’s problem with ineffective control of type 1 diabetes is identified when a sudden decrease in blood glucose level is followed by rebound hyperglycemia. What should the nurse do when this event occurs?
Give the client a glass of orange juice.
Seek an order to increase the insulin dose at bedtime.
Encourage the client to eat smaller, more frequent meals.
Collaborate with the health care provider to alter the insulin prescription.
16. Using Piaget’s theory of cognitive development, what should the nurse expect a 6-month-old infant to demonstrate?
Early traces of memory
Beginning sense of time
Repetitious reflex responses
Beginning of object permanence
17. A client who has just had a kidney transplant is transferred from the postanesthesia care unit (PACU) to the intensive care unit (ICU). How often should the nurse in the ICU monitor the client’s urinary output?
Every hour.
Every 2 hours.
Every half hour.
Every 15 minutes.
18. A person on the beach sustains a deep partial-thickness burn because of a severe sunburn. What is the best first-aid measure that a nurse should instruct the person to apply before seeking health care?
Cool, moist towels
Dry, sterile dressings
Analgesic sunburn spray
Vitamin A and D ointment
19. A health care provider explains a cystectomy and an ileal conduit to a client with invasive carcinoma of the bladder. Later the client expresses concerns about the possibility of offensive odors associated with this procedure. What is the best response by the nurse?
“Tell me more about what you are thinking.”
“Products are available to limit this problem.”
“This is a problem, but the surgery is necessary.”
“Most people who have this surgery share this same concern.”
20. A client with the diagnosis of personality disorder with antisocial behavior is hospitalized. The client is openly discussing interpersonal difficulties with family members and the boss at work from whom money has been stolen. The client presently is facing criminal charges. Which behavior indicates that the client is meeting treatment goals?
Expression of feelings of resentment toward the employer
Discussion of plans for each of the possible outcomes of a trial
Expression of resignation about difficult spousal and children relationships
Discussion of the decision to file a grievance against the employer after discharge from the hospital
21. A child is found to be allergic to dust. The nurse is preparing a teaching plan for the parents. What should the nurse include in the plan?
Housework must be done by professional house cleaners.
Damp-dusting the house will help limit dust particles in the air.
The condition must be accepted because dust in a house cannot be limited.
The house must be redecorated because the environment must be dust-free.
22. A client who has breast cancer had postlumpectomy chemo therapy and is now scheduled for radiation on an outpatient basis. What is an important nursing intervention while the client is receiving radiation?
Assess the radiated site daily for redness or irritation.
Rinse the radiated site with an antibacterial solution after each treatment.
Instruct the client to apply lotion twice daily to the skin on the radiated area.
Encourage the client to wear a snug-fitting bra between radiation treatments.
23. A nurse is caring for a client with glaucoma. What rationale associated with the need for treatment of this condition should the nurse include in a teaching program?
Total blindness is inevitable.
Lost vision cannot be restored.
Use of both eyes usually is restricted.
Surgery will help the problem only temporarily.
24. A client reports experiencing nausea, dyspnea, and right upper quadrant pain unrelieved by antacids. The pain occurs most often after eating in fast-food restaurants. Which diet should the nurse instruct the client to follow?
Low fat
Low carbohydrate
Soft-textured and bland
High protein and kilocalories
25. A client with a history of gambling has legal difficulties for embezzling money and is required to obtain counseling. During an intake interview, the client says, “I never would have done this if I had been paid what I am worth.” What factor will create the greatest difficulty when assisting this client to develop insight?
Peelings of boredom and emptiness
Grandiosity related to personal abilities
Projection of reasons for difficulties onto others
Anger toward those who are in authority positions
26. Which nursing action should be included in the plan of care for a child with acute poststreptococcal glomerulonephritis?
Encouraging fluids
Monitoring for seizures
Measuring abdominal girth
Checking for pupillary reactions
27. A nurse is caring for a newborn with a myelomeningocele. What should immediate nursing care for this infant include?
Changing diapers immediately when moist
Placing the infant in the reverse Trendelenburg position
Applying sterile, moist, nonadherent dressings to the sac
Positioning the infant prone with the legs slightly adducted
28. What is the most important test the nurse should check to determine whether a transplanted kidney is functioning?
Renal ultrasound
Serum creatinine level
White blood cell count
Twenty-four-hour urinary output
29. A nurse is caring for an older adult who is taking acetaminophen (Tylenol) for the relief of chronic pain. Which substance is most important for the nurse to determine the client is taking because it intensifies the most serious adverse effect of acetaminophen?
Alcohol
Caffeine
Saw palmetto
St. John’s wort
30. The parents of a child who is dying of cancer ask the nurse whether they should tell their 7-year-old son that his sister is dying. What is the most appropriate response by the nurse?
“Your child cannot comprehend the real meaning of death, so don’t tell him until the last moment.”
“Your son probably fears separation most and wants to know that you will care for him, rather than what will happen to his sister.”
“You should talk this over with your health care provider, who probably knows best what is happening in terms of your daughter’s prognosis.”
“Your son probably doesn’t understand death as we do but fears it just the same. He should be told the truth to let him prepare for his sister’s possible death.”
31. A person sustains deep partial-thickness burns while working on a boat in a town marina and seeks advice from the nurse in the first aid station. The nurse encourages the client to seek medical attention, but the client refuses. The nurse advises the person to go to a health care provider if:
blisters appear.
urinary output decreases.
edema and redness occur.
low-grade fever develops.
32. A nurse administers an intramuscular injection of vitamin K to a newborn. What is the purpose of the injection?
Maintains the intestinal floral count
Promotes proliferation of intestinal flora
Stimulates vitamin K production in the baby
Provides protection until intestinal flora is established
33. A child with acute poststreptococcal glomerulonephritis requests a snack. Which is the most therapeutic selection of food the nurse can provide?
Peanuts
Pretzels
Bananas
Applesauce
34. A client who has been on a psychiatric unit for several weeks continually talks about delusional material. What response by the nurse is most therapeutic?
Ask the client to explain the delusion.
Allow the client to maintain the delusion.
Encourage the client to focus on reality issues.
Explain to the client why the thoughts are not true.
35. An internal fetal monitor is applied while a client is in labor. What should the nurse explain about positioning while the monitor is in place?
The most comfortable position can be assumed.
Monitoring is more accurate in the side-lying position.
The monitor leads can be detached when sitting on the bedpan.
Maintaining a supine position holds the internal electrode in place.
36. Which is most important for the nurse to do when providing care to a client who has had a transurethral resection of the prostate?
Maintain patency of the cystostomy tube.
Ensure patency of the indwelling catheter.
Keep the abdominal dressing clean and dry.
Observe the wound for hemorrhage and infection.
37. What should the nurse do to assess the neurovascular status of an extremity casted from the ankle to the thigh?
Palpate the femoral artery.
Assess for a positive Homan sign.
Compress and release the clients toenails.
Instruct the client to flex and extend the knee.
38. On the third postpartum day, a woman who is breastfeeding calls the nurse at the clinic and asks why her breasts are tight and swollen. What should the nurse consider before explaining why her breasts are engorged?
There is an overabundance of milk.
Breastfeeding probably is ineffective.
The breasts have been inadequately supported.
The lymphatic system in the breasts is congested.
39. A client with major depression is admitted to the hospital. What is the most therapeutic initial nursing intervention?
Introducing the client to one other client
Requiring participation in therapy sessions
Encouraging interaction with others in small groups
Conveying an attitude of concern that is not intrusive
40. A client on a psychiatric unit who has been hearing voices is receiving a neuroleptic medication for the first time. The client takes the cup of water and the pill and stares at them. What is the most therapeutic statement the nurse can make?
“You have to take your medicine.”
“Your doctor wants you to have this medicine. Swallow it.”
“There must be a reason why you don’t want to take your medicine.”
“This is the medication that your doctor ordered for you to make you well.”
41. A client who has just started on a regimen of haloperidol (Haldol) is observed pacing and shifting weight from one foot to another. What side effect does the nurse document in the clients chart?
Akathisia
Parkinsonism
Tardive dyskinesia
Acute dystonic reaction
42. Which statement by a client with type 2 diabetes indicates to the nurse that additional teaching about the diet is needed?
“I can eat as much dietetic fruit as I want.”
“I can have a lettuce salad whenever I want it.”
“I know that half of my diet should be carbohydrates.”
“I need to reduce the amounts of saturated fats in my diet.”
43. A nurse is assessing a newborn. What finding indicates the need for follow-up care?
Babinski reflex is positive.
Head circumference is 33 cm.
Hips are abducted at 30 degrees.
Umbilical cord has three vessels.
44. A health care provider orders daily sputum specimens to be collected from a client. When is the most appropriate time for the nurse to collect these specimens?
After activity
Before meals
On awakening
Before a respiratory treatment
45. A nurse in the prenatal clinic is assessing a woman at 34 weeks’ gestation. The client’s blood pressure is 166/100 mm Hg and her urine is +3 for protein. She states that she has a severe headache and occasional blurred vision. Her baseline blood pressure was 100/62 mm Hg. What is the priority nursing action?
Arrange transportation to the hospital.
Obtain a prescription for an antihypertensive.
Recheck the blood pressure within half an hour.
Obtain a prescription for acetaminophen to relieve the headache.
46. A child has cystic fibrosis. Which statement by the parents about their plan for the child’s dietary regimen provides evidence that they understand the nurse’s instructions?
“I will restrict fluids during mealtimes.”
“I will discontinue the use of salt when cooking.”
“I should provide high-calorie foods between meals.”
“I should eliminate whole-milk products from the diet.”
47. A client is extubated in the postanesthesia care unit after surgery. For which common response should the nurse be alert when monitoring the client for acute respiratory distress?
Restlessness
Bradycardia
Constricted pupils
Clubbing of the fingers
48. After a therapy session with a health care provider in the mental health clinic, a client tells the nurse that the therapist is uncaring and impersonal. What is the nurse’s best response?
“Your therapist is really very good.”
“I hope that the rest of the staff is caring.”
“The therapist is there to help you; try to cooperate.”
“You have strong feelings about your therapy session and your therapist.”
49. A client has a urinary retention catheter in place after surgery. What should the nurse do when planning for the client’s safety needs in relation to this device?
Empty the bag every six hours.
Maintain the tension on the tubing.
Keep the system closed at all times.
Attach the bag to the side rail of the bed.
50. A nurse admits an adolescent to the psychiatric unit with the diagnosis of anorexia nervosa. What is the primary gain a client with anorexia achieves from this disorder?
Reduction of anxiety through control over food
Separation from parents secondary to hospitalization
Release from school responsibilities because of illness
Increased parental attentiveness related to massive weight loss
