1. Nurse Jessie is caring for an elderly woman who has had a fractured hip repaired. In the first few days following the surgical repair, which of the following nursing measures will best facilitate the resumption of activities for this client?
a. arranging for the wheelchair
b. asking her family to visit
c. assisting her to sit out of bed in a chair qid
d. encouraging the use of an overhead trapeze
2. What do you think is the most important nursing order in a client with major head trauma who is about to receive bolus enteral feeding?
a. measure intake and output.
b. check albumin level.
c. monitor glucose levels.
d. increase enteral feeding.
3. What is the pathological process causing esophageal varices is
a. ascites and edema.
b. systemic hypertension.
c. portal hypertension.
d. dilated veins and varicesitis.
4. Which of the following interventions will help lessen the effect of GERD (acid reflux)?
a. Elevate the head of the bed on 4-6 inch blocks.
b. Lie down after eating.
c. Increase fluid intake just before bedtime.
d. Wear a girdle.
5. What is the main benefit of therapeutic massages is:
a. to help a person with swollen legs to decrease the fluid retention.
b. to help a person with duodenal ulcers feel better.
c. to help damaged tissue in a diabetic to heal.
d. to improve circulation and muscles tone.
6. Which of the following foods should be avoided by clients who are prone to develop heartburn as a result of gastroesophgeal reflux disease (GERD)?
7. Which of the following should be included in a plan of care for a client receiving total parenteral nutrition (TPN)?
a. Withhold medications while the TPN is infusing.
b. Change TPN solution every 24 hours.
c. Flush the TPN line with water prior to initiating nutritional support.
d. Keep client on complete bed rest during TPN therapy.
8. Which of the following should be included in a plan of care for a client who is lactose intolerant?
a. Remove all dairy products from the diet.
b. Frozen yogurt can be included in the diet.
c. Drink small amounts of milk on an empty stomach.
d. Spread out selection of dairy products throughout the day.
9. Pain tolerance in an elderly patient with cancer would:
a. stay the same.
b. be lowered.
c. be increased.
d. no effect on pain tolerance.
10. What is the main advantage of cutaneous stimulation in managing paint:
a. costs less.
b. restricts movement and decreases.
c. gives client control over pain syndrome.
d. allows the family to care for the patient at home.
11. The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to
a. exercise doing weight bearing activities
b. exercise to reduce weight
c. avoid exercise activities that increase the risk of fracture
d. exercise to strengthen muscles and thereby protect bones
12. A client in a long term care facility complains of pain. The nurse collects data about the client’s pain. The first step in pain assessment is for the nurse to
a. have the client identify coping methods
b. get the description of the location and intensity of the pain
c. accept the client’s report of pain
d. determine the client’s status of pain
13. Which statement best describes the effects of immobility in children?
a. Immobility prevents the progression of language and fine motor development
b. Immobility in children has similar physical effects to those found in adults
c. Children are more susceptible to the effects of immobility than are adults
d. Children are likely to have prolonged immobility with subsequent complications
14. After a myocardial infarction, a client is placed on a sodium restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate to suggest?
a. 3 oz. broiled fish, 1 baked potato, ½ cup canned beets, 1 orange, and milk
b. 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple
c. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice
d. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange
15. A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers?
a. A 79 year-old malnourished client on bed rest
b. An obese client who uses a wheelchair
c. An incontinent client who has had 3 diarrhea stools
d. An 80 year-old ambulatory diabetic client
16. Ms. Kelly. has had a CVA (cerebrovascular accident) and has severe right-sided weakness. She has been taught to walk with a cane. The nurse is evaluating her use of the cane prior to discharge. Which of the following reflects correct use of the cane?
a. Holding the cane in her left hand, Ms. Kelly. moves the cane forward first, then her right leg, and finally her left leg
b. Holding the cane in her right hand, Ms. Kelly. moves the cane forward first, then her left leg, and finally her right leg
c. Holding the cane in her right hand, Ms. Kelly. moves the cane and her right leg forward, then moves her left leg forward.
d. Holding the cane in her left hand, Ms. Kelly. moves the cane and her left leg forward, then moves her right leg forward
17. The nurse is instructing a woman in a low-fat, high-fiber diet. Which of the following food choices, if selected by the client, indicate an understanding of a low-fat, high-fiber diet?
a. Tuna salad sandwich on whole wheat bread.
b. Vegetable soup made with vegetable stock, carrots, celery, and legumes served with toasted oat bread
c. Chef’s salad with hard boiled eggs and fat-free dressing
d. Broiled chicken stuffed with chopped apples and walnuts
18. An 85-year-old male patient has been bedridden for two weeks. Which of the following complaints by the patient indicates to the nurse that he is developing a complication of immobility?
a. Stiffness of the right ankle joint
b. Soreness of the gums
c. Short-term memory loss.
d. Decreased appetite.
19. An eleven-month-old infant is brought to the pediatric clinic. The nurse suspects that the child has iron deficiency anemia. Because iron deficiency anemia is suspected, which of the following is the most important information to obtain from the infant’s parents?
a. Normal dietary intake.
b. Relevant sociocultural, economic, and educational background of the family.
c. Any evidence of blood in the stools
d. A history of maternal anemia during pregnancy
20. A 46-year-old female with chronic constipation is assessed by the nurse for a bowel training regimen. Which factor indicates further information is needed by the nurse?
a. The client’s dietary habits include foods high in bulk.
b. The client’s fluid intake is between 2500-3000 ml per day
c. The client engages in moderate exercise each day
d. The client’s bowel habits were not discussed.