1. The nurse should anticipate that a client brought to the emergency
room with methadone intoxication will be given which of the following
A. Proventil (albuterol). B. Valium (diazepam).
C. Narcan (naloxone). D. Demerol (meperidine).
2. Which of the following statements, if made by a client who has
chronic paranoid schizophrenia, would indicate a correct
understanding of the discharge instructions for antipsychotic
A. “I will take this medication daily.”
B. “I will take the medication when I start to feel anxious.”
C. “I will need to take this medication for at least six months.”
D. “I won’t need as much medication after I leave the hospital.”
3. An amniotomy is conducted on a client labor. The nurse should
monitor the client for which of the following adverse effects?
A. Fetal heart rate deceleration. B. Fetal heart rate acceleration.
C. Leaking of copious amount of clear fluid. D. Little or no amniotic fluid
4. Which of the following recommendations should the nurse make to
a pregnant adolescent
who has an aversion to milk?
A. “It’s important to drink milk during pregnancy even though you don’t like it.”
B “Milk products are not necessary as long as you take a daily 1200 mg calcium
C. “Adequate protein intake can be achieved by eating 2 eggs everyday.”
D. “Adequate calcium intake can be achieved by eating a cup of spinach everyday.”
. The nurse is about to remove sutures on an Arabic male recovering
from a colon resection.
The client’s son, daughter and wife are with him. The nurse should
realize that in the client’s culture:
A. family members participate in the client’s care.
B. only a male family member may remain in the room during treatment
C. a male nurse is the only acceptable care provider.
D. all family members have to approve any procedures.
1. A 2-day postoperative client suddenly becomes diaphoretic, dusky
and short of breath. The nurse’s immediate response should be to
A. transfer the client to the cardiac intensive care unit.
B. begin cardiopulmonary resuscitation.
C. administer oxygen.
D. lower the head of the bed.
2. A client who has a fractured hip is admitted to the hospital. The
client’s hygiene is poor and her clothing is soiled. The nursing
assistant says, “Isn’t this disgusting? I can’t believe anyone would
take such poor care of herself.” The nurse’s most appropriate
response would be:
A. “Let’s get her cleaned up.” B. “You sound upset.”
C. “I totally agree. This is awful.” D. “Not everyone is as fortunate as
3. A one-week-old breast fed infant is voiding 3 times a day. The
mother asks the nurse if this is normal. The best response by the
A. “If the baby looks healthy, there should b no problem.”
B. “It is expected that the newborn will have least 1 wet diapers a day.”
C. “Maybe your milk supply is low.”
D. “Wet diapers normally vary greatly among newborns. There is no set number of
voids considered normal.”
4. During an initial home visit post-hospitalization, the nurse note that
the client has a history of recent stroke with residual left sided
hemiparesis, slight aphasia, diminished gag reflex and emotional
liability. The client outcome of highest priority is ability to:
A. communicate effectively.
B. perform activities of daily living (ADLs) with assistance.
C. ambulate with assistance.
D. swallow liquids and solids without aspiration.
10. Which of the following statements made by a client during a
teaching session about osteoporosis management indicates the need
for further instruction?
A. “I drink about 1 cups of tea a day, so I need to reduce my caffeine intake.”
B. “I need to eat more seafood and dried beans.”
C. “I will have to limit the amount of walking that I do.”
D. I will talk to my doctor about the pros and cons of hormone replacement therapy.
11. The nurse is assigned to a client with a diagnosis of terminal
cancer and an order for comfort measures only. Which of the following
nursing interventions would have the highest priority for this client?
A. Performing a body systems assessment
B. Measuring oxygen saturation level
C. Assessing pain status
D. Repositioning for comfort
12. A client has been taking Zoloft (sertraline) for three months.
Which of the following client statements indicates a need for further
A. I am taking my medication every week.
B. I take my medication with breakfast.
C. I am eating more cheese and fresh fruit in my diet.
D. I enjoyed drinking several beers with my friends last night.
13. The home health nurse assists a client with acquired immune
deficiency syndrome (AIDS) to assess for pseudo membranous
candidiasis by observing for:
A. white plaques on oral surfaces.
B. cracking and erythema of the nares.
C. red, painful lesions in the outer ear canal.
D. conjunctivitis of either or both eyes.
14. To facilitate swallowing by a dysphagic client, the nurse should
use which of the following techniques at mealtime?
A. Have the client eat in a brightly lit, stimulating dining room.
B. Offer the client only room temperature foods
C. Encourage the client to alternate thickened liquids and solids in small amounts.
D. Encourage the client to hyperextend his neck when swallowing.
1. A client is admitted to the emergency department following an
automobile accident. The client has four fractured ribs and a right
sided pneumothorax. Which of the following respiratory assessment
findings would the nurse expect to find?
A. Crackles on the right chest and a respiratory rate of 3 breaths/minute.
B. Diminished breath sounds on the right and pain on inspiration.
C. Bilateral rhonchi and pink frothy sputum.
D. Dry cough and wheezing on the right side of the chest.
11. The clinic nurse should monitor which of the following tests to
evaluate the over-all therapeutic compliance of a diabetic client with a
normal serum hemoglobin?
A. Fasting serum glucose
B. Glycosylated hemoglobin
C. Urine glucose and ketone levels
D. Routine serum chemistry profile
12. A registered nurse and an unlicensed assistive personal (UAP) are
assigned to a medical
Surgical unit. Which of the following tasks may be delegated by the
nurse to the UAP?
A. Administering a stool softener to the client
B. Adjusting the rate of the intravenous solution of dextrose and water
C. Assisting a blind client with his meal
D. Obtaining initial vital signs on a client returning from the recovery room
13. Which of the following physical assessment findings should
indicate to the nurse that a client who received a renal transplant one
month ago is experiencing acute organ rejection?
A. Distended abdomen. B. Pink, sensitive incisional line.
C. Lower extremity edema. D. Tenderness in lower abdomen.
14. Which of the following breathing patterns would indicate to the
nurse that a client with chronic asthma has improved respiratory
A. A rate of exhalation twice that of inhalation
B. A rate of inhalation twice that of exhalation
C. Slow, shallow inhalation
D. Slow, shallow exhalation
20. When administering methylprednisolone (Solu-Medrol) to a client
with IDDM (insulin dependent diabetes mellitus) the nurse would expect
the client’s insulin requirement to
C. remain stable.
D. fluctuate widely.
21. A client with a thought disorder approaches the nurse and states,
“I’m an Easter egg”. The nurse’s best response would be:
A. “No, you’re not an Easter egg.”
B. “Tell me what you’re thinking when you say that.”
C. “O.K., but you still need to attend groups.”
D. “How long have you been feeling that way?”
22. Which of the following statements would be most appropriate for
the nurse to make when teaching a client with human papilloma virus
A. “You may need to be treated again.”
B. “You may resume your normal level of activity.”
C. “You should have a pap smear.”
D. “You need to continue your medication until symptoms subside.”
23. The nurse is teaching a hypertensive client about management of
the disease. Which of these client statements indicates the greatest
need for further instruction?
A. “I can continue swimming 3 times a week.”
B. “I drink alcohol only on weekends.”
C. “I will visit an eye doctor yearly.”
D. “Relaxation for me is going to the movies.”
24. The most appropriate action for the nurse from geriatric care unit
to take when asked to report for a shift in the surgical intensive care
unit would be to
A. refuse the assignment immediately.
B. notify the state board of nurse examiners.
C. accept responsibility only for tasks for which the nurse is qualified.
D. say nothing and comply with the request.
2. The nurse should instruct a client preparing for eye surgery that
which of these activities
will be restricted post-operatively?
A. Bending with the knees flexed. B. Bending from the waist.
C. Keeping the head in a neutral position. D. Lying flat.
21. The nurse is caring for a gravely ill young woman in the intensive
care unit who has requested that the “pyramid” brought in by her
family be placed under her bed. The best action by the nurse would be
A. comply with the client’s wishes.
B. ask the family to take it home because it will be in the way.
C. put it on the window ledge because of the equipment needed in the room.
D. hang it from an intravenous pole to keep it away from medical equipment.
22. A new mother is worried that her baby will have trouble breathing
while breastfeeding. The nurse should instruct the mother that the
safest way to breastfeed is to:
A. depress the breast tissue around the baby’s nose.
B. pull the nipple out of the baby’s mouth and let him breathe periodically.
C. raise the baby’s hips slightly to change the angle of the head for breathing.
D. make sure only the baby’s cheeks touch the breast, not the nose and chin.
23. A client who was in a motor accident one month ago has been
having flashbacks of the event. The nurse’s priority intervention during
a flashback would be to:
A. engage the client in alternate activities.
B. initiate behavioral modification techniques.
C. stay with the client.
D. teach progressive relaxation exercises.
24. A new mother is breastfeeding her infant who is making loud
clicking noises at the breast. The best intervention by the nurse would
A. gently pull the baby off the breast and reposition.
B. listen for audible swallowing.
C. observe to make sure the entire areola is in the baby’s mouth.
D. not intervene with the breast feeding process.
30. Four clients are admitted to the hospital following a car accident.
Which of the following clients should the nurse assess first?
A. A 22 year old complaining of a headache.
B. An 13 year old with a compound fracture of the right arm.
C. A 2 year old with blood on both pant legs.
D. A 20 year old with epistaxis.
31. A client who just returned to his room after a transurethral
prostatectomy (TURP) has continuous three-way bladder irrigation. The
nurse notes that the drainage is dark red without clots. Which of the
following actions should the nurse take?
A. Increase the rate of irrigation. B. Notify the physician.
C. Continue to monitor the drainage. D. Irrigate the catheter manually
3. Which of these discharge instructions should the nurse give to a
client taking atorvastatin (Lipitor)?
A. “Wear sunglasses and use sunscreen when you are outdoors.
B. “You must take the medication with a meal.
C. “You may experience some minor muscle cramps.
D. “Taking fat-soluble vitamins will promote absorption of the drug.
31. The nurse caring for a client with an obsessive compulsive
disorder should encourage the client to:
A. abruptly stop the ritualistic behavior.
B. decrease the amount of time spent with family members who exacerbate the
C. increase the amount of time spent practicing the ritualistic behavior.
D. use thought- stopping behavior that allows that client to yell “ stop” when the
Comes to mind.
32. Which of the following interventions should be added to the
nursing care plan for a client who has difficulty swallowing after a
A. Avoid salty foods. B. Thicken liquids before feeding.
C. Elevate head of bed 310 degrees. D. Place food in center of mouth.
33. A nurse making a home visit to a client with a central line
discovers a possible occlusion.
Which of the following actions would the nurse implement initially
before notifying the physician?
A. Infuse a thrombolytic agent. B. Change the client’s position.
C. Have an X-ray taken. D. Flush the line with sterile water.
34. Which information is most important for the nurse to include in a
teaching plan for a client with a laryngectomy?
A. Contact a self-help group after discharge
B. Protect the airway from dust
C. Purchase special steroid cream for the stoma
D. Maintain an upright position while eating and drinking
40. A client’s infant is scheduled to have a circumcision. He is crying
inconsolably and the mother appears distraught. The nurse should
explain to the mother that the infant
A. is probably hungry since he hasn’t eaten for a few hours.
B. is probably frightened because babies sense danger.
C. wants attention like most babies.
D. probably needs to be swaddled more tightly.
41. Which of these laboratory findings would indicate that simvastatin
(Zocor) is having the desired effect?
A. Lowered high density lipoproteins (HDL)
B. Decreased triglycerides
C. Elevated alanine aminotransferase (ALT)
D. Increased aspartate aminotransferase (AST)
42. The nurse suspects a client has been smoking crack cocaine when
she observes which of the following assessment findings?
A. Euphoria and dilation of the pupil
B. Red eyes and increased appetite
C. Drowsiness and constricted pupils
D. Depressed appetite and hallucinations
43. A psychotic client is pacing, kicking the wall and talking loudly to
himself. The best nursing response to this behavior would be to
A. place the client in restraints immediately.
B. approach the client and tell him that his behavior is inappropriate and needs to
C. offer the client a choice of talking about what’s upsetting him or spending some
quiet time in his room.
D. tell the client that if he doesn’t stop kicking the wall, you will put him in restraints.
44. During the nursing history, a client states, “I have anemia”. The
nursing care plan should
include measures to:
A. promote hydration B. prevent infection
C. alleviate fatigue. D. protect skin integrity.
4. Which of the following nursing actions should be included in the
care plan for a client with acute hypercalcemia?
A. Monitor vital signs every hour.
B. Administer pain medication every 4 hours.
C. Encourage fluid intake to >2000ml/day.
D. Assess for numbness and tingling of extremities.
41. The physician orders interferon alfa-2b for a client with hepatitis
C. The nurse should assess the client for which of these side effects of
A. Constipation. B. Bradycardia.
C. Insomnia. D. Fatigue.
42. Which of the following would be a nursing priority for discharge
planning of the aging client?
A. Educating the client and family to remove throw rugs from the client’s apartment.
B. Speaking loudly to be certain that the client can hear you.
C. Encouraging the client to switch to a soft diet with fruit.
D. Recommending a low cholesterol diet to decrease risk of heart disease.
43. The best position for the client who is admitted with risk of
increased intracranial pressure from a concussion would be:
A. Trendelenburg. B. Semi-fowler's.
C. Sim’s lateral. D. Supine.
44. A client sustains a life-threatening head injury in a motor vehicle
accident and is admitted to the hospital. The client’s wife approaches
the nurse and asks, “Is he going to die?” The nurses best response
A. We won’t let that happen. I know how much he means to you.”
B. I will get the physician to talk to you as soon as possible.”
C. He is very ill, and we’re doing the best we can for him.
D. His condition is very serious and I will arrange for you to see him.
0. Which of the following post-procedure instructions should be
included in the teaching plan for a client undergoing an arteriogram of
the lower extremities?
A. Nothing by mouth for at least 2 hours after the procedure.
B. Increased fluid intake for the first 4 hours after the procedure.
C. Conduct full range of motion exercises of the affected limb.
D. Remove pressure dressing after 1 hour.
1 C 2 A 3 A 4 B 5 A 6 C 7 B 8 B
9B 10 B
11 D 12 C 13 C 14 D 15 A 1٦B 17 C
18 B 19 B 20 C
21 D 22 A 23 A 24 B 25 A 26 B 27 C
28 B 29 A 30 C
31 C 32 B 33 A 34 A 35 A 36 D 37A
38 B 39 B 40 A
41 B 42 A 43 B 44 C 45 C 46 D 47 A
48 B 49 D 50 B