1. Nurse Fiona is teaching a client who receives nitrates for the relief of chest pain. Which of the following instructions should the nurse emphasize?
a. Repeat the dose of sublingual nitroglycerin every 15 minutes for three doses
b. Store the drug in a cool, well-lit place
c. Lie down or sit in a chair for 5 to 10 minutes after taking the drug
d. Restrict alcohol intake to two drinks per day
2. After an amniotomy, nurse Sally is aware that the client goal should take the highest priority?
a. The client will express increased knowledge about amniotomy
b. The client will maintain adequate fetal tissue perfusion
c. The client will display no signs of infection
d. The client will report relief of pain
3. A client is admitted with suspected cirrhosis. During assessment, nurse Lennie is most likely to detect:
a. an increase in chest hair
b. muscle wasting
c. testicular hypertrophy
d. an increased clotting tendency
4. A male client on mechanical ventilation is receiving pancuronium bromide (Pavulon), 0.01 mg/kg I.V. as needed. Which assessment finding indicates that the client needs another pancuronium dose?
a. Leg movement
b. Finger movement
c. Lip movement
d. Fighting the ventilator
5. When inspecting a client’s skin, nurse Kate finds a vesicle on the client’s arm. Which description applies to a vesicle?
a. Flat, nonpalpable, and colored
b. Solid, elevated, and circumscribed
c. Circumscribed, elevated, and filled with serous fluid
d. Elevated, pus-filled, and circumscribed
6. Nurse Jinky is assessing a client with heart failure. To assess hepatojugular reflux, the nurse should:
a. elevate the client’s head to 90 degrees
b. press the right upper abdomen
c. press the left upper abdomen
d. lie the client flat in bed
7. A male client with lung cancer has developed an intractable, nonproductive cough that is unrelieved by nonnarcotic antitussive agents. Dr. Rodriguez prescribes codeine, 10 mg P.O. every 4 hours. Which statement accurately describes codeine?
a. It’s a centrally acting antitussive and doesn’t cause dependence
b. It’s a peripherally acting antitussive and doesn’t cause dependence
c. It’s a centrally acting antitussive and can cause dependence
d. It’s a peripherally acting antitussive and can cause dependence
8. A client with human immunodeficiency virus (HIV) infection delivers a neonate. When assessing the neonate, nurse Edwin is most likely to detect:
a. skin vesicles
b. limb dysmorphism
9. Nurse Ronald is teaching a client with chronic bronchitis about breathing exercises. Which of the following should the nurse include in the teaching?
a. Make inhalation longer than exhalation
b. Exhale through an open mouth
c. Use diaphragmatic breathing
d. Use chest breathing
10. Nurse Maureen notices that a depressed client taking amitriptyline (Elavil) for 2 weeks has become very outgoing, cheerful, and talkative. The nurse suspects that the client:
a. is responding to the antipsychotic
b. may be experiencing increased energy and is at an increased risk for suicide
c. is ready to be discharged from treatment
d. is experiencing a split personality
11. When caring for children who are sick, who have sustained traumas, or who are suffering from nutritional inadequacies, nurse Yvette should know the correct hemoglobin (Hb) values for children. Which of the following ranges would be inaccurate?
a. Neonates: 10.6 to 16.5 g/dl
b. 3 months: 10.6 to 16.5 g/dl
c. 3 years: 9.4 to 15.5 g/dl
d. 10 years: 10.7 to 15.5 g/dl
12. A female client is diagnosed with osteoporosis. Which electrolytes are involved in the development of this disorder?
a. Calcium and sodium
b. Calcium and phosphorous
c. Phosphorous and potassium
d. Potassium and sodium
13. A client who used heroin during her pregnancy delivers a neonate. When assessing the neonate, nurse Diana expects to find:
a. lethargy 2 days after birth
b. irritability and poor sucking
c. a flattened nose, small eyes, and thin lips
d. congenital defects such as limb anomalies
14. A male adult client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem?
a. Give the feedings at room temperature
b. Decrease the rate of feedings and the concentration of the formula
c. Place the client in semi-Fowler’s position while feeding
d. Change the feeding container every 12 hours
15. The role of nurse Hans regarding complementary and alternative medicine (CAM) should include:
a. Recommending herbal remedies that the client should use
b. Educating the client about “good” versus “bad” therapies
c. Discouraging the client from using any alternative therapies
d. Educating the client about therapies that he or she is using or is interested in using
16. An antihypertensive medication has been prescribed for a client with hypertension. The client tells nurse Michelle that she would like to take an herbal substance to help lower her blood pressure. The nurse should take which appropriate action?
a. Tell the client that herbal substances are not safe and should never be used.
b. Advise the client to discuss the use of an herbal substance with the physician
c. Teach the client how to take her blood pressure so that it can be monitored closely.
d. Tell the client that id she takes the herbal substance she will need to have her blood pressure checked frequently.
17. Nurse Jonathan understands that which of the following statements regarding herbal therapies is true?
a. Zinc is used for insomnia
b. Ginger is used to improve memory
c. Echinacea is used for erectile dysfunction
d. Black cohosh produces estrogen-like effects.
18. Nurse Angel has just assisted a client back to bed after a fall. The nurse and physician have assessed the client, and have determined that the client is not injured. After completing the incident report, the nurse should take which action next?
a. Reassess the client
b. Conduct a staff meeting to describe the fall
c. Document in the nurse’s notes that an incident report was completed
d. Contact the nursing supervisor to update information regarding the fall
19. Nurse Michael is reading a physician’s progress notes in the client’s record and reads that the physician has documented “insensible fluid loss of approximately 800mL daily.” The nurse understands that this type of fluid loss can occur through:
a. The skin
b. Urinary output
c. Wound drainage
d. The gastrointestinal tract
20. Nurse Deric is assigned to care for a group of clients. On review of the clients’ medical records, the nurse determines that which client is at risk for deficient fluid volume?
a. A client with a colostomy
b. A client with congestive heart failure
c. A client with decreased kidney function
d. A client receiving frequent wound irrigations
21. Nurse Dominique caring for a client who has been receiving intravenous diuretics suspects that the client is experiencing a deficient fluid volume. Which assessment finding would the nurse note in a client with this condition?
a. Lung congestion
b. Decreased hematocrit
c. Increased blood pressure
d. Decreased central venous pressure (CVP)
22. Nurse Joy is assigned to care for a group of clients. On review of the clients’ medical records, the nurse determines that which client is at risk for excess fluid volume?
a. The client taking diuretics
b. The client with renal failure
c. The client with an ileostomy
d. The client who requires gastrointestinal suctioning
23. Nurse Stephanie is caring for a client with congestive heart failure. On assessment, the nurse notes that the client is dyspneic and that crackles are audible on auscultation. The nurse suspects excess fluid volume. What additional signs would the nurse expects to note in this client if excess fluid volume is present?
a. Weight loss
b. Flat neck and hand veins
c. An increase in blood pressure
d. A decreased central venous pressure (CVP)
24. Nurse Rivette is preparing to care for a client with a potassium deficit. The nurse reviews the client’s record and determines that the client was at risk for developing the potassium deficit because the client:
a. Has renal failure
b. Requires nasogastric suction
c. Has a history of Addison’s disease
d. Is taking a potassium-sparing diuretic
25. Nurse Louie reviews a client’s electrolyte laboratory report and notes that the potassium level is 3.2 mEq/L. which of the following would the nurse note on the electrocardiogram as a result of the laboratory value?
a. U waves
b. Absent P waves
c. Elevated T waves
d. Elevated ST segment