1. Which intervention is an example of primary prevention?
a. Administering digoxin (Lanoxicaps) to a patient with heart failure
b. Administering a measles, mumps, and rubella immunization to an infant
c. Obtaining a Papanicolaou smear to screen for cervical cancer
d. Using occupational therapy to help a patient cope with arthritis
2. The nurse in charge is assessing a patient’s abdomen. Which examination technique should the nurse use first?
3. Which statement regarding heart sounds is correct?
a. S1 and S2 sound equally loud over the entire cardiac area.
b. S1 and S2 sound fainter at the apex
c. S1 and S2 sound fainter at the base
d. S1 is loudest at the apex, and S2 is loudest at the base
4. The nurse in charge identifies a patient’s responses to actual or potential health problems during which step of the nursing process?
b. Nursing diagnosis
5. A female patient is receiving furosemide (Lasix), 40 mg P.O. b.i.d. in the plan of care, the nurse should emphasize teaching the patient about the importance of consuming:
a. Fresh, green vegetables
b. Bananas and oranges
c. Lean red meat
d. Creamed corn
6. The nurse in charge must monitor a patient receiving chloramphenicol for adverse drug reaction. What is the most toxic reaction to chloramphenicol?
a. Lethal arrhythmias
b. Malignant hypertension
c. Status epilepticus
d. Bone marrow suppression
7. A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive highest priority at this time?
a. Impaired gas exchanges related to increased blood flow
b. Fluid volume excess related to peripheral vascular disease
c. Risk for injury related to edema
d. Altered peripheral tissue perfusion related to venous congestion
8. When positioned properly, the tip of a central venous catheter should lie in the:
a. Superior vena cava
b. Basilica vein
c. Jugular vein
d. Subclavian vein
9. Nurse Margareth is revising a client’s care plan. During which step of the nursing process does such revision take place?
10. A 65-year-old female who has diabetes mellitus and has sustained a large laceration on her left wrist asks the nurse, “How long will it take for my scars to disappear?” which statement would be the nurse’s best response?
a. “The contraction phase of wound healing can take 2 to 3 years.”
b. “Wound healing is very individual but within 4 months the scar should fade.”
c. “With your history and the type of location of the injury, it’s hard to say.”
d. “If you don’t develop an infection, the wound should heal any time between 1 and 3 years from now.”
11. One aspect of implementation related to drug therapy is:
a. Developing a content outline
b. Documenting drugs given
c. Establishing outcome criteria
d. Setting realistic client goals
12. A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor would the nurse recognize as most important?
a. A history of increased aspirin use
b. Recent pelvic surgery
c. An active daily walking program
d. A history of diabetes
13. Which intervention should the nurse in charge try first for a client that exhibits signs of sleep disturbance?
a. Administer sleeping medication before bedtime
b. Ask the client each morning to describe the quantity of sleep during the previous night
c. Teach the client relaxation techniques, such as guided imagery, medication, and progressive muscle relaxation
d. Provide the client with normal sleep aids, such as pillows, back rubs, and snacks
14. While examining a client’s leg, the nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressings is most appropriate for the nurse in charge to apply?
a. Dry sterile dressing
b. Sterile petroleum gauze
c. Moist, sterile saline gauze
d. Povidone-iodine-soaked gauze
15. A male client in a behavioral-health facility receives a 30-minute psychotherapy session, and provider uses a current procedure terminology (CPT) code that bills for a 50-minute session. Under the False Claims Act, such illegal behavior is known as:
16. A nurse assigned to care for a postoperative male client who has diabetes mellitus. During the assessment interview, the client reports that he’s impotent and says that he’s concerned about its effect on his marriage. In planning this client’s care, the most appropriate intervention would be to:
a. Encourage the client to ask questions about personal sexuality
b. Provide time for privacy
c. Provide support for the spouse or significant other
d. Suggest referral to a sex counselor or other appropriate professional
17. Using Abraham Maslow’s hierarchy of human needs, a nurse assigns highest priority to which client need?
18. A male client is on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal?
a. Inadequate vitamin D intake
b. Inadequate protein intake
c. Inadequate massaging of the affected area
d. Low calcium level
19. A female client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?
a. Acute pain related to surgery
b. Deficient fluid volume related to blood and fluid loss from surgery
c. Impaired physical mobility related to surgery
d. Risk for aspiration related to anesthesia
20. Nurse Cay inspects a client’s back and notices small hemorrhagic spots. The nurse documents that the client has:
21. Which document addresses the client’s right to information, informed consent, and treatment refusal?
a. Standard of Nursing Practice
b. Patient’s Bill of Rights
c. Nurse Practice Act
d. Code for Nurses
22. If a blood pressure cuff is too small for a client, blood pressure readings taken with such a cuff may do which of the following?
a. Fail to show changes in blood pressure
b. Produce a false-high measurement
c. Cause sciatic nerve damage
d. Produce a false-low measurement
23. Nurse Danny has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein?
a. Baked beans, hamburger, and milk
b. Spaghetti with cream sauce, broccoli, and tea
c. Bouillon, spinach, and soda
d. Chicken cutlet, spinach, and soda
24. A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first nursing priority for this client would be to:
a. Assess the client’s airway
b. Provide pain relief
c. Encourage deep breathing and coughing
d. Splint the chest wall with a pillow
25. A newly hired charge nurse assesses the staff nurses as competent individually but ineffective and nonproductive as a team. In addressing her concern, the charge nurse should understand that the usual reason for such a situation is:
a. Unhappiness about the charge in leadership
b. Unexpected feeling and emotions among the staff
c. Fatigue from overwork and understaffing
d. Failure to incorporate staff in decision making
26. A male client blood test results are as follows: white blood cell (WBC) count, 100ul; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 40%. Which goal would be most important for this client?
a. Promote fluid balance
b. Prevent infection
c. Promote rest
d. Prevent injury
27. Following a tonsillectomy, a female client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. Which position would be most therapeutic for this client?
28. Nurse Berri inspects a client’s pupil size and determines that it’s 2 mm in the left eye and 3 mm in the right eye. Unequal pupils are known as:
29. The nurse in charge is caring for an Italian client. He’s complaining of pain, but he falls asleep right after his complaint and before the nurse can assess his pain. The nurse concludes that:
a. He may have a low threshold for pain
b. He was faking pain
c. Someone else gave him medication
d. The pain went away
30. A female client is admitted to the emergency department with complaints of chest pain shortness of breath. The nurse’s assessment reveals jugular vein distention. The nurse knows that when a client has jugular vein distension, it’s typically due to:
a. A neck tumor
b. An electrolyte imbalance
d. Fluid overload